arterial peripheral vascular examination

Question 1

overview

Answer 1

1 - the intro 
2 - inspection
3 - palpation
4 - ascultation 
5 - special tests

Question 2

steps of the intro

Answer 2

1 - WIPER

exposure is to underwear and supine on the bed.

Q Are you in any pain at all?
Q Are you able to stand comfortably?
Q Screen for claudication – Distance, Rest relief, Hanging legs down at night

Question 3

steps of inspection

Answer 3

Inspection

Colour: Pale/ Blue/ Purple/ Black

Trophic changes - Shiny skin, hair loss, skin thinning

Signs: Gangrene patches, Oedema, Amputations

Ulcers: Size, shape, depth, edge, base

Pressure points: Check heel, malleoli, first metatarsal, lateral side of foot, toes (especially between), dorsum of foot

Question 4

steps of palpation

Answer 4

Upper limbs
- Inspect hands for nicotine staining
- Compare radial & brachial pulses bilaterally
- Checks for radial-radial delay AND radio-femoral delay
- Offers to measure & compare blood pressure on both sides and states that
>15mmHg difference is abnormal

Eyes/Neck

• Inspect eyes for corneal arcus and xanthelasma
• Carotid pulses (each side individually)

Abdomen
- Palpate for abdominal aortic aneurysm

Lower limbs

• Femoral pulses (checking for radio-femoral delay)
• Popliteal pulses (if too easy to feel possible aneurysm)
• Posterior tibial and dorsalis pedis pulses
• Palpates for temperature change distally-proximally
• Measure capillary refill time on toes

Question 5

ascultation steps

Answer 5

Auscultate
Neck - Both carotid arteries
Abdomen - Renal bruits
Lower limbs - Femoral artery bruits in the adductor canal

Question 6

special tests

Answer 6

1 - buerger’s test - comment on burger’s angle and venous guttering.

Special Tests
Buerger’s Test- looking for Buerger’s Angle and Reactive Hyperaemia

Question 7

what is burger’s test

Answer 7

The vascular angle, which is also called Buerger’s angle, is the angle to which the leg has to be raised before it becomes pale. In a limb with a normal circulation the toes stay pink, even when the limb is raised by 90 degrees. In an ischaemic leg, elevation to 15 degrees or 30 degrees for 30 to 60 seconds may cause pallor. A vascular angle of less than 20 degrees indicates severe ischaemia.[1]

In arterial disease, on returning the leg from the raised position, and hanging it over the side of the bed, the leg will revert to the pink colour more slowly than normal. Moreover, the affected leg will pass through the normal pink colour to a red-range colour (often known as sunset foot) due to the dilatation of the arterioles in their attempt to remove the metabolic waste that has built up, through the phenomenon of reactive hyperaemia. Finally, the limb will then revert to its normal colour.

Question 8

ending the examination

Answer 8

1 - complete. ask pt if they need help getting changed and thank them.
2 - offer Cardiovascular Examination, upper limb, carotid pulses, carotid bruits, radial-femoral delay.
3 - off AAA, ABPI, neuro limbs.
4 - present findings in a logical and structured way and offer a diagnosis.

Question 9

Femoral artery

Answer 9

Femoral artery – feel both together, auscultate and also time with the radial artery.
The midpoint of the inguinal ligament, which stretches between the anterior superior iliac spine and
the pubic symphysis.

Question 10

Popliteal artery

Answer 10

Popliteal artery – feel in both flexed and extended positions.
Need to get the patient to relax hamstrings and calf muscles – flex the patient’s knee and place the
thumbs of both hands on the tibial tuberosity. Use the pulps of the fingers to palpate the
neurovascular bundle against the posterior surface of the upper end of the tibia.

Question 11

Posterior tibial artery

Answer 11

Posterior tibial artery – feel.

Midway between the medial malleolus and the heel.

Question 12

Dorsalis pedis artery

Answer 12

Dorsalis pedis artery – feel.
Felt along a line that extends between the middle of a line drawn between the two malleoli and the
webspace between the first and second toe (congenitally absent in 10% of people).

Question 13

How would you measure an ankle-brachial pressure index?

Answer 13

This is a measure of how well perfused the legs/feet are. Need a hand-held Doppler and a sphygmomanometer. Measure the brachial blood pressure and record the systolic pressure. Then put the Doppler over the three pedal arteries in turn (dorsalis pedis, posterior tibial and perforating
peroneal) whilst inflating the cuff. The pressure at which the
Doppler signal disappears is the systolic pressure of that artery as it passes under the cuff. Take the highest pedal artery pressure and work out: foot artery/brachial artery.

In health, ABPI should be 1+ in supine position.

Claudication:

Question 14

What signs, other than you’ve looked for, might you expect to find in vascular disease?

Answer 14

Hands: Nicotine stains
Raynaud’s syndrome
Wasting of small muscles of hand (thoracic outlet syndrome)
Calcinosis (Scleroderma and the CREST syndrome)
Face: Corneal arcus and xanthelasma (hypercholesterolaemis)
Horner’s syndrome (carotid artery problems)
Prominent neck veins (axillary/subclavian vein occlusion)
Abdomen: Epigastric/umbilical pulsation (AAA)

Question 15

Remember the 6 P’s of acute limb ischaemia:

Answer 15

Pulseless, pallor, perishing cold, parasthesia, paralysis, and pain and squeezing muscles.

Question 16

How do you record pulses in notes?

Answer 16

Normal +
Reduced +/-
Absent -
Aneurysmal ++