Peripheral Vascular Disease Examination

Question 1

What is the first step in the exam?

Answer 1

Introduce self
Confirm patient’s name and DOB
Explain procedure “ Today I have been asked to perform an examination of your blood vessels, this will involve me having a look at your arms and legs and listening to your pulses” is that okay?

Question 2

What do you do after the introduction?

Answer 2

You do a general inspection of the limbs

Question 3

What are you looking for on general inspection of the limbs from the end of the bed?

Answer 3

Missing digits/limbs
Scars
Ulcers
Cyanosis
Pallor

Around the bed -

Mobility aids
Medical equipment

Question 4

What do you do after the general inspection?

Answer 4

Inspection of the upper limbs

Question 5

What are you looking for on inspection of the upper limbs?

Answer 5

Colour - Pallor/Cyanosis/Erythema
Finger tip necrosis
Tar staining
Tendon xanthomas

Question 6

What do you do after inspecting the upper limbs?

Answer 6

Temperature of both arms comparatively

Capillary Refill TIme of one finger tip

Question 7

What do you do after feeling the temperature and taking the CRT of the upper limbs?

Answer 7

Pulses -

Radial pulse - rate and rythym

Radio-Radial delay ( palpate both radial pulses simultaneously )

Brachial pulse - medial, assess the volume and character

Offer to take BP

Question 8

What do you do after finishing examination of the upper limb?

Answer 8

Auscultate the carotid artery ( using diaphragm and ask patient to take a deep breath and hold it)

Question 9

What are you listening for on auscultation of the carotid artery?

Answer 9

Carotid bruit - indicated carotid stenosis

Could also be a radiation of the aortic stenosis murmur

Question 10

What do you do after auscultating the carotid artery?

Answer 10

If no bruits heard, proceed to palpation

Place fingers between the larynx and SCM - assess character

Question 11

What do you do after palpating the carotid artery?

Answer 11

Inspect the abdomen for pulsation (AAA)

Question 12

What do you do after inspecting the abdomen?

Answer 12

Palpate the Abdominal aorta - hands should move superiorly, if they move outwards it suggests AAA)

Question 13

What do you do after palpating the abdominal aorta?

Answer 13

Auscultate the aorta ( 1-2cm superior to the umbilicus)

Auscultate the renal arteries ( move stethoscope slightly lateral to where it is for aorta )

Listening for bruits

Question 14

What do you do after auscultating the abdominal vessels?

Answer 14

Inspection of the lower limb and between toes ( ulcers)

Question 15

What are you looking for on inspection of the lower limb?

Answer 15

Colour - Cyanois, Pallor, Ischaemic rubor

Venous ulcers ( large and shallow, irregular borders, commonly on medial malleolus)

Arterial ulcers ( small, well-defined, deep and painful, develop on ends of digits)

Gangrene

Missing toes, limbs

Scars
Hair loss
Muscle wasting ( PVD)
Xanthomata ( knee/ankle)

Question 16

What do you do after inspection of the lower limb?

Answer 16

Ask patient to wiggle toes ( gross motor assessment)

Question 17

What do you do after gross motor assessment of the lower limb?

Answer 17

Assess temperature on both sides simultaneously

Measure capillary refill time of toe

Question 18

What do you do after assessing temperature and CRT of lower limb?

Answer 18

Pulses -

Femoral Pulse ( Mid-inguinal point, halfway between ASIS and pubic symphysis, show yourself locating the asis and also the pubic symphysis ( track down in the midline near the bladder to find the bony prominence of the symphysis)

Radio-femoral delay ( Palpate femoral and radial pulse simultaneously )

AUSCULTATE the femoral pulse for bruits

Popliteal pulse ( Ask patient to flex knee and feel in popliteal fossa against the tibia, place all 4 fingers of both hands in the popliteal fossa and thumbs on patella and press deeply to feel)

Posterior tibial pulse ( posterior to the medial malleolus and then compare on both sides)

Dorsalis pedis pulse ( lateral to extensor hallucis longus tendon , over the 2nd and 3rd cuneiform - lower than you think , bones and then compare)

Feel pulses against a bone

Question 19

What do you do after assessing the pulses of the lower limb?

Answer 19

Sensation

Ask the patient to close their eyes whilst you touch their sternum with a wisp of cotton wool to provide an example of light touch sensation.

2. Ask the patient to say “yes” when they feel the sensation.
3. Using the wisp of cotton wool, begin to assess light touch sensation moving distal to proximal, comparing each side as you go by asking the patient if it feels the same:

If sensation is intact distally, no further assessment is required.
If there is a sensory deficit, continue to move proximally until the patient is able to feel the cotton wool and note the level at which this occurs.

Question 20

What do you do after assessing the sensation of the lower limb?

Answer 20

Buerger’s Test

With patient lying on their back , lift both their legs simultaneously for 1-2 minutes

In a healthy patient - the leg should remain pink

If pallor happens , indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion

Note the angle this occurs ( less than 20 degrees indicates severe limb ischaemia)

Sit the patient up and ask them to hang their legs down over the side of the bed

Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb.
The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue. Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation (driven by anaerobic metabolic waste products).

Question 21

How would you present the findings?
What would you also ask to perform at the end of the exam?

Answer 21

Today I performed a peripheral vascular examination on ….
- On general inspection there was nothing of note
- On inspection of the upper limb…, the temperature was symmetrically warm/cold , the CRP was normal/prolonged
- The radial pulse had a regular rate of … and regular rhythm
- There was no radio-radial delay
- The brachial pulse was weak/strong
- I could not hear any carotid bruits, and the carotid pulse had a normal volume on palpation
- There was no visible pulsation on the abdomen , and no aortic or renal bruits were present
- There were no findings of note on inspection of the legs, they felt warm, and had a normal CRT
- The gross motor ability was intact
- The pulses were all present , no femoral bruit was present
-The sensation of the lower limbs was intact

I would also do Brueger’s Test
I would also take the BP of both arms, do a full cardiovascular examination and measure the patient’s Ankle-Brachial Pressure Index