Peripheral Vascular Examination

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Introduction

  • Wash Your hands
  • Introduce yourself by name and Role
  • Check the patient’s identity – name and Date of Birth
  • Explain the procedure – why you need to do it and what does it involve
  • Ask for consent
  • Expose the patient appropriately
  • Check if the patient is currently in any pain
How to Introduce Yourself

“Good morning, my name is .. and I am a medical student. Can I just check your name and date of birth?

I have been asked to do a peripheral vascular examination on you, which would involve me having a look at your hands, face and chest, and then having a feel and listen to your chest. Is that ok?

– For the purposes of this examination I’m just going to position the bed at 45 degrees.

– Would you mind removing your shirt for me please?

– And can I just check whether you are in any pain?”

Bedside Inspection

  • Observe the patient by standing at the end of the bed.
  • Comment on whether the patient is ABC:

A – Alert         B – (normal) Body habitus         C – Comfortable at rest

  • Observe the surroundings and comment of whether you can see any “paraphernalia of cardiovascular disease”:

This is a description of the objects or items around a patient’s bedside that will give you an idea into the condition that they might have. It is important to highlight this to the examiner as this can give you many clues about the patient’s underlying diagnosis. Things to look for include: 

  • Oxygen – is the patient currently on oxygen or room air, and what is the flow rate?
  • Inhalers – does the patient have underlying respiratory disease?
  • Medication – can you see any medication on the patient’s bedside e.g. beta-blockers?
  • Test results – are there any investigation results like ECGs lying around the patient’s bedside.
  • Fluid chart – this gives you an idea if they are fluid overloaded.
  • Pillows – this is a useful marker of the level of heart failure as it shows that the patient might be suffering from orthopnea.
  • Mobility aids – gives an idea about the functional status of the patient.

 

Arms

INSPECTION:

Action:

Ask the Patient to hold out their arms. Inspect the arms carefully for the following features:

Assess for:

–> Scars: This increased vessel harvesting scars for previous cardiovascular surgery like a CABG

–> Peripheral Cyanosis: This is a blue discolouration of the nails and fingers which is indicative of peripheral ischaemia. It shows the patient is peripherally not perfusing well which can be seen in shock or hypothermia. 

–> Tar staining: This is a black/brown staining of the nails and fingers which is seen in chronic smokers. 

–> Koilonychia: These are spoon-shaped nails which are seen in iron-deficieny anaemia. 

–> Loss of digits: These are a consequence of end organ ischaemia which may have resulted in the digits being amputated. Therefore it is important to count the number of digits in the hands. 

–> Extensor Tendon Xanthomata: These are small non-tender lumps of cholesterol that can be found of the tendons of the extensor muscles of the wrist and palms. They are seen in hyperlipidaemia. 

Tar Staining

Seen in chronic smokers

Koilonychia

Associated with iron deficiency anaemia

Dry Gangrene

Associated with critical limb ischaemia

PALPATION:

Action: Ask the Patient to put their hands outstretched. Using the back of your hands, feel down from their forearms to feel the temperature:

Assess for:

–> Cold peripheries: This is a sign of poor peripheral circulation. This is a common sign of shock and so may occur in hypovolaemia when the arterioles are vasoconstricted to reduce blood supply to the extremities. 

Action: Pinch the patient’s fingernail for 5 seconds and then release. Measure the capillary refill time.

Assess for:

–> Capillary refill time: This is the time taken for the capillaries to refill after a sustained period of pressure. Apply 5 seconds of pressure to the distal phalanx of the index finger and then release. Count how many seconds it taken to go red (re-vascularise). If >2 seconds, this shows poor peripheral circulation which could be a sign of shock. 

 

PULSES

Action: Feel for the Radial Pulse on one side and measure the radial pulse for 15 seconds

Assess for:

–> Rate (bpm),  rhythm (regular, regularly irregular, irregularly irregular) and character (thready, bounding): 

What the Radial Pulse Tells You

The radial pulse gives you a lot of information about the state of the cardiovascular system. There are 3 main variables to talk about when measuring the radial pulse:

1. Rate:

– A rate of <60bpm is considered bradycardia

– A rate of >100bpm is considered tachycardia

2. Rhythm: There are 3 main rythms to talk about:

– Regular – this will most likely be due to sinus rhythm, however you can get this in ventricular tachycardia

– Regularly irregular – this will most likely be due to a form of heart block

– Irregularly irregular – this is one not to miss and is most likely due to atrial fibrillation.

3. Character – this is gives you an indication of the strength of the impulse. It can be:

– Thready – can be seen if the BP is low such as in shock if the patient is peripherally shutting down

– Bounding – seen in CO2 retention. 

Action: Feel for the brachial pulse in the antecubital fossa. This will give you a better indicator of the character of the pulse compared to the radial pulse. 

Action: At this point, state that you would mention the blood pressure in both arms.

 

Head and Neck

INSPECTION

Action: Ask the patient to pull their eyelid down with their finger and look up.

Assess for:

–> Conjunctival Pallor: This is a paleness of the conjunctiva which is a sign of anaemia

Action: Ask the patient to relax and look at their eyes. 

Assess for:

–> Corneal Arcus: This is  a deposit of cholesterol, phospholipids, and triglycerides in an “arc” on either the top or bottom side of the iris, which is a sign of hypercholesterolaemia. This is a risk factor for cardiovascular disease.

–> Xanthelasma: These are yellowish-white lumps of fatty material accumulated under the skin on the inner parts of your upper and lower eyelids, which are associated with hyperlipidaemia. 

Conjunctival Pallor

Associated with anaemia

Corneal Arcus

Associated with hyperlipidaemia

Xanthelasma

Associated with hyperlipidaemia

PULSES

Action: Check the carotid pulse. First have a listen and then a feel to the carotid pulse side by side 

Assess for:

–> Carotid bruits: These are sounds which indicate turbulent flow. They may indicate atherosclerosis to the carotids which demonstrate that the patient has established cardiovascular disease. 

Chest and Abdomen

INSPECTION

Action: Ask patient to lie down supine and inspect their chest and abdomen for a variety of features.

Assess for:

–> Scars:

  • Lateral thoracotomy scar – may indicate previous mitral valvotomy
  • Median sternotomy scar –indicates presence of previous coronary artery bypass or cardiac valve surgery
  • Subclavian scar – site for  pacemaker

–> PULSATILE MASS: A large pulsatile mass in the abdomen is suggestive of an abdominal aortic aneurysm. 

PALPATE

Action: Using two hands, press down on the abdomen just superior to the umbilicus. Place both hands there and see if you can feel a movement in your fingers

Assess for:

–> Abdominal Aneurysm: This is a dilation of the abdominal aorta >50% of its original diameter.

– When feeling a normal aorta will feel pulsatile and you hands should move superiorly with each pulse

– If there is AAA, your hands will move upward and outwards, showing it is a dilated expansile mass. 

AUSCULTATE

Action: Using your stethoscope, have a listen to the abdominal aorta and the renal arteries:

– For renal arteries – place your stethoscope 2cm lateral and superior to the umbilicus

– For aorta, listen 2cm superior to the umbilicus

Assess for:

–> Bruits: This is an audible vascular sound which is associated with turbulent blood flow. This shows that the blood flow is being disrupted either due to a problem with the artery (e.g. aneurysm) or factors which narrow the lumen e.g. atherosclerosis.

Legs

INSPECTION

Action: Ask the patient to keep their legs outstretched. Closely inspect their feet and legs for any signs of cardiovascular disease.

Assess for:

–> Scars: Look for vein harvesting scars for a CABG. The great saphenous vein is often used as the graft for a coronary bypass surgery, so this will indicate that the patient has ischaemic disease. 

–> Varicose veins: These are dilated and tortuous veins secondary to chronic venous insufficiency

–> Peripheral Cyanosis: This is a blue discolouration of the nails and fingers which is indicative of peripheral ischaemia. It shows the patient is peripherally not perfusing well which can be seen in shock or hypothermia. 

–> Trophic Changes:  These are cutaneous changes that appear due to diabetes and peripheral neuropathy. They often start off as callous formation but also include shiny skin, loss of hair. 

–> Ulcers: Describe margin, colour, wet/dry and location

–> Loss of digits: These are a consequence of end organ ischaemia which may have resulted in the digits being amputated. Therefore it is important to count the number of digits in the hands. 

Varicose Veins

Associated with venous insufficiency

Diabetic Foot Ulcer

Associated with moderate-severe diabetes

Venous Ulcer

Associated with moderate-severe diabetes

Vein Harvesting Scar

Associated with cardiovascular surgery e.g. CABG

PALPATION:

Action: Ask the Patient to keep their legs outstretched. Using the back of your hands, feel down from their thighs to feel the temperature:

Assess for:

–> Cold peripheries: This is a sign of poor peripheral circulation. This is a common sign of shock and so may occur in hypovolaemia when the arterioles are vasoconstricted to reduce blood supply to the extremities. 

Action: Pinch the patient’s toenail for 5 seconds and then release. Measure the capillary refill time.

Assess for:

–> Capillary refill time: This is the time taken for the capillaries to refill after a sustained period of pressure. Apply 5 seconds of pressure to the distal phalanx of the index finger and then release. Count how many seconds it taken to go red (re-vascularise). If >2 seconds, this shows poor peripheral circulation which could be a sign of shock. 

 

PULSES

Action: Feel for the pulses in the lower limb and then auscultate them. Compare the pulses side by side.

Assess for:

–> Femoral pulse: This is found in the femoral triangle. Mention if you can feel it or not, the volume and whether you can listen to any bruits. 

–> Popliteal Pulse: Assess this pulse with the knee flexed for 45 degrees

–> Posterior tibial: This pulse is found 1cm posterior to the medial malleolus. 

-> Dorsalis pedis: This pulse is detected on the dorsum of the foot between the 2nd/3rd cuneiform bones

 

SENSATION

Action: Perform a gross sensory assessment of the lower limb.

a. Ask the patient to close their eyes. Using a piece of cotton wool, tap the patient on the sternum to show them what it should feel like.

b. Ask the patient to say “yes” when they feel the cotton wool.

c. Using the wisp 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 up the legs to the point where they can feel it.

Assess for:

–> Peripheral Neuropathy: This is common in patients which limb ischaemia of diseases like diabetes. Patient with diabetes will typically lose sensation in a glove and stocking distribution.

 

Special Tests

BUERGER’S TEST

Action:

a. Get the patient to lie flat and slowly elevate both legs simultaneously to 45 degrees for 2 mins. 

b. Observe the colour of their legs and whether they start to go pale

c. In a healthy individual, the legs should remain pink as they should have a good cardiovascular blood supply

– In patients witch cardiovascular disease the legs will go pale. Note the angle at which the legs go pale – this is known as Buerger’s angle. An angle of <20 degrees suggests severe ischaemia.

d. Once time has elapsed, place the legs hanging 90 degrees over the edge of the bed. 

– In ischaemia, the foot will turn pink slowly, but then become a dark pink/red after 2 minutes. This is a reactive hyperaemia due to the hypoxia causing dilation of the arterioles. 

Thank the patient and wash your hands to complete the examination!

On Completion

You must remember that the physical examination is only one part of the overall assessment of your patient. Therefore, when completing your exam, state that you would do the following in order to complete your assessment of the patient. Much of this will depend on whether you have discovered any particular findings or have an idea about the overall diagnosis. However, some essential things to talk about are:

“To complete the examination, I would do a number of steps…”

Bedside – (History) Take a full history

  • (Observations) Full Obs chart including blood pressure
  • (Corresponding examination) Conduct a cardiovascular examination
  • (Bedside tests) Measure blood glucose and urine dip for renal disease/glucosuria

Bloods – Would take a full blood count + U&Es and lipid profile

Imaging – (Dependent on findings)

Special tests – Ankle brachial pressure index (with Doppler Ultrasound) 

How to Present Your Findings

“I conducted a peripheral examination on … who seemed well and comfortable at rest.

  • On inspection there were no peripheral signs of peripheral vascular disease and no paraphernalia of cardiovascular disease.
  • They had a pulse rate of … There was no radio-radial delay, and their pulse was regular and character normal
  • There were no abdominal or renal bruits
  • The pulses were palpable bilaterally in the lower limb and there was normal sensation
  • Buerger’s test was normal

In summary, this is a normal examination.”

Sources

Tar Staining – James Heilman, MD, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Koilonychia – CHeitz, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

Dry Gangrene – See page for author, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons 

Conjunctival Pallor –  Sheth TN, Detsky AS. The relation of conjunctival pallor to the presence of anemia. J Gen Intern Med. 1997;12(2):102-106.

Corneal Arcus –  Loren A Zech Jr and Jeffery M Hoeg, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

Xanthelasma –  Klaus D. Peter, Wiehl, Germany, CC BY 3.0 DE <https://creativecommons.org/licenses/by/3.0/de/deed.en>, via Wikimedia Commons

AAA – BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons 

Varicose Veins – self, Public domain, via Wikimedia Commons

DIabetic Ulcer – Mark A. Dreyer, DPM, FACFAS, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons

Venous Ulcer – Nini00, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Vein Harvesting – Timpo, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

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