Lower limb peripheral vascular examination

Question 1

What do you do first in a introduction?

Answer 1

Wash hands

Introduce yourself

Patient details - Name, DOB (+age)

Question 2

Explain a LLPV exam to a patient

Answer 2

I’ve been asked to examine the blood supply to your legs today,

it’s going to involve me having a general inspection of your legs, face and chest before having a feel of your pulses in your legs and listening with my stethoscope.

Question 3

What else would you say before starting the exam?

Answer 3

For this I’m going to need you to take your top and pants off if that’s okay?

Would you like a chaperone?

Ask if patient currently has any pain or discomfort.

Question 4

What do you inspect in a LLPV exam?

Answer 4

General

Bedside

Eyes

Mouth

Abdomen

Legs

Feet

Toes

Question 5

When inspecting generally / bedside what are you looking for?

Answer 5

Are they comfortable at rest?

Any mobility aids, dressings or limb prosthesis.

Look for evidence of cyanosis or pallor of the limbs.

Question 6

When inspecting the eyes what are you looking for?

Answer 6

Conjunctival pallor

Corneal arcus

Question 7

When inspecting the mouth what are you looking for?

Answer 7

Central cyanosis

Dehydration

Question 8

When inspecting the what abdomen are you looking for?

Answer 8

Scars

Visible masses

Visible pulsations

Question 9

When inspecting the legs, feet and toes what are you looking for?

Answer 9

Scars

Hair loss

Discolouration

Pallor

Missing limbs/toes

Muscle wasting

Ulcers

Question 10

Why might someones legs have scars?

Answer 10

Bypass surgery/vein harvest sites

Question 11

What is hair loss on the legs associated with?

Answer 11

PVD

Question 12

What would you want to rule out in the legs, feet or toes are dicoloured?

Answer 12

?Necrosis

Question 13

What would pallor of the lower limbs indicate?

Answer 13

Poor arterial supply

Question 14

When would someone be missing limbs / toes?

Answer 14

Previous amputation

Question 15

What can lower limb muscle wasting be associated with?

Answer 15

PVD

Question 16

When inspecting an ulcer what do you want to assess?

Answer 16

Site

Depth

Size

Margins

Ulcer bed

Exudate

Ordour

Question 17

Where do you want to look for ulcers other than the shin area and dorsum of the foot?

Answer 17

Between toes

Posterior aspect of legs

Question 18

Describe arterial ulcers

Answer 18

Very painful.
Punched out appearance.
Located at end of digits, sole or lateral surface of ankle.

Question 19

What pulses do you palpate in a LLPVE?

Answer 19

Abdo aorta

Fermoral pulses

Popiteal pulses

Posterior tibial pulses

Dorsalis pedis pulses

Question 20

Where can you feel the femoral pulse?

What do you assess?

Answer 20

Best palpated at mid-inguinal point (halfway between anterior superior iliac spine + pubic symphysis).

Assess volume.
Assess for radio-femoral delay;

Question 21

If there is a radio-fermoral delay present what could this indicate?

Answer 21

Aortic coarctation

Question 22

Where can you feel the popiteal pulse?

Answer 22

Best palpated in the inferior region of the popliteal fossa.

Patient prone, ask them to relax legs, thumbs on tibial tuberosity, passively flex knee to 30° + curl fingers into the popliteal fossa feeling the pulse as you compress the popliteal artery against the tibia.

Question 23

Where can you feel the posterior tibial pulse?

What do you assess?

Answer 23

Best palpated posterior to the medial malleolus of the tibia.

Assess volume
Compare both feet

Question 24

Where can you feel the dorsalis pedis pulse?

What do you assess?

Answer 24

Best palpated over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the 2nd and 3rd cuneiform bones.

Assess volume + compare to other foot.

Question 25

What type of sensation do you want to assess in the LLPV exam?

Where should you start?

Answer 25

Light touch sensation

starting distally to identify limb paraesthesia which can be a symptom of acute limb ischaemia.

Question 26

Where do you assess power in the LLVP exam?

Answer 26

Legs + foot

Hip flex + exten
Knee flex + exten
ankle dorsi + plantar flexion
toe - dorsi + plantar flexion

Question 27

Where do you auscultate in the LLVP exam?

What do you listen for?

Answer 27

Abdo aorta
Fermoral arteries

Bruits

Question 28

How do you perform Buerger’s test?

Answer 28

Patient supine, elevate both legs to 45° and hold for 1–2 minutes.

Sit patient up + ask them to hang legs down over the side of the bed at 90°.

Gravity aids blood flow + colour returns in the ischaemic leg.

The time it takes to become pink/red relates to the severity of ischaemia (Buerger’s time).

Both legs examined simultaneously.

Question 29

In buerger’s test what does pallor indicate?

Answer 29

ischemia

Question 30

What is Beurger’s angle?

What angle is considered to indicate severe limb ischaemia?

Answer 30

Poorer the arterial supply, the less the angle to which the legs have to be raised for them to become pale

<20 degrees

Question 31

After completelting the exam what do you do first?

Answer 31

Wash hands

Thank patient

Question 32

To complete my exam…

Answer 32

I’d like to perform an upper limb peripheral arterial examination, measure the ABPI, BP, perform a foot examination and measure the blood glucose
Doppler for venous insufficiency if needed

Question 33

Summarise a normal LLPV exam

Answer 33

Today I performed an upper limb peripheral arterial examination on ____ a ___ year old ___.

On general inspection, ___ appeared comfortable at rest.

There was no peripheral stigmata of peripheral arterial disease.

Abdominal aortic pulse was not palpable and there were no audible bruits.

Pulses were present bilaterally in lower limbs and had normal rate, rhythm and character
The pulse was ___bpm

Sensation of the lower limb was intact

To conclude, this is consistent with a normal lower limb peripheral arterial examination