Peripheral Vascular Examination
The peripheral vascular examination is a series of maneuvers to elicit signs of peripheral vascular pathology. As with many examination stations, this examination follows the usual procedure of Look, Feel, Listen (or Inspect, Palpate, Auscultate).
Ensure that your patient is lying comfortably on the bed. Ideally they should be exposed from the abdomen down, however for the purposes of an exam, the patient will probably be wearing shorts.
Perform a general observation of the patient, noting whether they are comfortable at rest as well as their general well-being. Comment on the general appearance of the legs, including any obvious abnormalities such as muscle wasting or scars.
Furthermore, note any appliances or medications which may be positioned around the bed.
Now focus the observation towards the patient's legs, feet and toes. Signs to note include:
- Any signs of gangrene or pre-gangrene such as missing toes or blackening of the extremities.
- The presence of any ulcers - ensure you check all around the feet, including behind the ankle. These may be venous or arterial - one defining factor is that venous ulcers tend to be painless whereas arterial are painful.
- Any skin changes such as pallor, change in colour (eg purple/black from haemostasis or brown from haemosiderin deposition), varicose eczema or sites of previous ulcers.
- Presence of any varicose veins - often seen best with the patient standing.
After completing the inspection, move onto palpating the legs. This should include an assessment of the temperature of each leg. Starting distally, feel with the back of your hand and compare the legs to each other noting any difference.
Check capillary return by compressing the nail bed and then releasing it. Normal colour should return within 2 seconds. If this result is abnormal, you may suggest to the examiner that you would like to perform Buerger's Test. This involves raising the patient's feet to 45 degrees. In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet over the side of the bed, cyanosis may then develop.
Any varicosities which you noted in the observation should now be palpated. If these are hard to the touch, or painful when touched, it may suggest thrombophlebitis.
Finally for palpation, you should feel for the abdominal aorta and each of the peripheral pulses. These are:
- Aorta ‚ this should be palpated just to the left of the midline in the epigastrium, note whether the pulsation in expansile as in an aneurysm.
- Femoral ‚ feel at the mid inguinal point, below the inguinal ligament.
- Popliteal ‚ ask the patient to flex their knee to roughly 45 degrees keeping their foot on the bed, place both hands on the front of the knee and place your fingers in the popliteal space.
- Posterior tibial ‚ felt posterior to the medial malleolus of the tibia.
- Dorsalis pedis ‚ feel on the dorsum of the foot, lateral to the extensor tendon of the great toe.
You should feel these on both sides and comment on their strength, comparing one side relative to the other.
Another maneuver on the pulses which should be performed is checking for radio-femoral delay. Palpate both the radial and femoral pulses on one side of the body. The pulsation should occur at the same time. Any delay may suggest coarctation of the aorta.
There is little to auscultate in a peripheral vascular examination. However, you should listen for femoral and abdominal aortic bruits.
On completion, thank the patient for their time and ensure they are comfortable and well-covered. Remember to wash your hands.