Peripheral Vascular Examination Flashcards
What clinical signs of underlying pathology are you looking for when performing the end-of-the-bed examination?
- Missing limbs/digits: critical ischaemia
- Scars: previous surgical procedures
What objects or equipment are you looking for on the end of the bed examination?
- Medical equipment: dressings and limb prosthesis
- Mobility aids: wheelchairs and walking aids
- Vital Signs
- Prescriptions
After the end of the bed examination is the inspection of the upper limbs, what are you looking for?
Inspect and compare the upper limbs:
- Peripheral cyanosis: poor perfusion
- Peripheral pallor: poor perfusion
- Tar staining: smoking
- Xanthomata: hyperlipidaemia
-Gangerene: tissue necrosis secondary to inaquedate perfusion
What comes next? After hands inspection
- Temperature
- CRT <2s -> abnormal and suggests poor peripheral perfusion
- Chech that they do not have any pain currently in their fingers prior
What pulses should you measure and what are you looking for?
- Radial pulse: Assess for rate and rhythm
- Radio-radial delay: Loss of synchronicity
(Subclavian artery stenosis or aortic dissection) - Brachial pulse: Assess the volume and character
- Carotid pulse
What procedure should you conduct when measuring the carotid pulse?
- Auscultate the carotid artery - bruit
- Make sure the patient takes a deep breath in and hold it whilst you listen
- it could in fact be a radiating cardiac murmur though - Palpate
- Assess the character and volume of the pulse
What comes next in the examination? After pulses
The Abdomen: make sure there is adequate exposure for abdominal examination -> position the waistband to the level of the pubic symphysis
What are the stages of the abdominal examination?
- Inspection
- Any obvious pulsation of the aorta - Palpate the aorta
- Use both hands to perform deep palpation just superior to the umbilicus in the midline
- Note movement of fingers
- Move hands outwards and note the presence of an expansile mass: aortic aneurysm - Ascultate the aorta and renal arteries
- To identify any vascular bruits -> turbulent blood flow
Where do you auscultate for aortic and renal arteries for bruits?
Aortic bruits: auscultate 1-2cm superior to the umbilicus: AAA
Renal bruits: auscultate 1-2cm superior to the umbilicus and slightly lateral to the midline on each side -> renal artery stenosis
What are you looking for in the lower limb inspection?
- Peripheral cyanosis
- Peripheral pallor
- Ischaemic rubour: rusty red discoloration of the leg
- Venous ulcers: medial aspect of ankle - nonpainful
- Arterial ulcers: end of digits - painful
- Gangrene
- Missing limbs, toes, fingers
- Scars
-Hair loss - Muscle wasting
- Xanthomata
- Paralysis
Make sure to look in between all the toes
What comes after a general inspection of the legs?
- Gross amperature -> movement
Temperature - CRT of toes
What pulses should you palpate for in the lower limb?
Make sure you work proximal to distal as it helps you to assess and compare arterial inflow into each leg -> if they are not palpable you can use a doppler
- Femoral pulse
- Mid-inguinal point: halfway between the anterior superior iliac spine and pubic symphysis
- Check the pulse is present and assess the pulse volume
-Check for radio-femoral delay
-Auscultate for bruits -> could suggest femoral or iliac stenosis - Popliteal pulse
- Palpated in the inferior region of the popliteal fossa
- With the patient supine ask them to relax their legs and place thumbs on the tibial tuberosity
- Flex the patients knee to 30 as you curl your fingers into the politeal fossa
- Hard to palpate so often wont - Tibial Pulse
- Located to the medial malleolus of the tibia
- Palpate the pulse to confirm its presence and then comapre pulse strength between the feet. - Dorsalis pedis pulse
- Located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones
- Palpate to confirm its presence and then compare pulse strength between the feet
What should you do after you have palpated for all the pulses?
Assess for sensation
1. Ask patients to close their eyes whilst they touch their sternum with a wisp of cotton wool to provide an example of a light tough sensation and ask them to say yes when they feel the sensation
- Then move distal to proximal on the legs comparing each side and seeing if the patient feels the same
- if intact distally (toes) then don’t need to go further.
What is the Buerger’s test and how do you conduct it?
- Patient supine and stand at the bottom of the bed and ask to raise both of the patient’s feet to 45 degrees for 1-2 minutes
- Observe color of the limbs -> pallor indicates bad vascularisation and notes what angle pallor persits
- Sit the patient up and hang their legs over the side of the bed
- gravity should return color to patient’s leg
How should you summarise the exam?
Today I examined Mr Smith, a 64-year-old male. On general inspection, the patient appeared comfortable at rest and there were no objects or medical equipment around the bed of relevance.”
“The upper limbs had no stigmata of peripheral vascular disease and were symmetrically warm, with a normal capillary refill time.”
“The pulse was regular and there was no radio-radial delay. On auscultation of the carotid arteries, there was no evidence of carotid bruits and on palpation, the carotid pulse had normal volume and character.”
“Abdominal examination was unremarkable.”
“The lower limbs had no stigmata of peripheral vascular disease and were symmetrically warm, with a normal capillary refill time. Pulses were normal throughout both lower limbs and there were no gross neurological deficits noted.”
“Buerger’s test was negative.”
“In summary, these findings are consistent with a normal peripheral vascular examination.”
“For completeness, I would like to perform the following further assessments and investigations.”
