Peripheral vascular system examination

1. Introduce yourself to the patient (you’ll probably be told they’re having pain in their legs), check
problem and patient name, obtain consent.

2. Get the patient lying down to start with – need the lower arms and all of the legs exposed.

3. Inspect from the end of the bed. You are looking for: scars, obvious ulcers/gangrene etc, how the
patient is holding their limbs, muscle atrophy.

4. Examine the radial pulse’s rate, rhythm, volume and character. Assess both radial pulses at once for
radial-radial delay.

5. Feel the brachial pulse both sides.

6. Say that you would like to measure the BP in both arms at this point.

7. Feel the carotid pulse both sides and also auscultate for bruits/murmurs.

8. Palpate and auscultate over the abdominal aorta.

9. Inspect the legs fully for: signs of (pre) gangrene; ulceration (describe if present); skin changes inc.
varicose eczema, loss of hair, pallor, damage from previous ulcers etc; scars from operations (groin, inner
thigh); varicosities.

10. Say if you thought you saw any varicosities you would ask the patient to stand so you could see them
better (increased venous filling on standing) –see later notes.

11. Ask the patient if they have any tenderness in their legs.

12. Comment on any difference in skin temperature – use the back of your hand and compare the two
legs. Start at the feet and move up – if it’s normal in the feet there’s little point in going on. Colder in
ischaemia (unless there is infection).

13. Look between the toes and at the heels for ischaemic changes and guttering (= chronic ischaemia of
the limb is associated with onset of extreme pallor of the foot and emptying – ‘guttering’ – of dorsal foot
veins with limb elevation.

14. Look for reduced capillary return by compressing a nail bed on each of the feet.

15. Palpate the arteries of the legs – comment on any difference in character between the two legs:

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.

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.

Posterior tibial artery – feel.

Midway between the medial malleolus and the heel.

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).

16. Elicit Buerger’s test – this is used as a rough guide to the degree of ischaemia in the leg. The leg is
elevated passively to 45o (it becomes pale and blanched in a poor arterial supply because it can’t be
perfused against gravity). Then ask the patient to hang their leg at 90o over the side of the bed – it
becomes cyanosed as the dilated vascular bed fills with deoxygenated blood. Check the mobility of the
patient’s leg before doing this.

17. Say that you would like to measure the ankle/brachial pressure index and examine the foot for
sensation.

Questions around the topic

How would you measure an ankle-brachial pressure index?

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: <0.8
Critical ischaemia: <0.4

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

**Remember the 6 P’s of acute limb ischaemia**:

Pulseless, pallor, perishing cold, parasthesia, paralysis, and pain and squeezing muscles.
How do you record pulses in notes?
Normal +
Reduced +/-
Absent -
Aneurysmal ++