Peripheral Vascular Exam

• Preparation

  • Wash hands

  • Positioning: supine

  • Draping: triangle tuck method

• Inspection

  • Abdomen

    • Look for pulsatile midline mass - periumbilical area

  • Lower legs:

    • SEADS

      • Swelling

      • Erythema

      • Atrophy/hypertrophy of muscles

      • Deformities

      • Skin change

    • Signs of arterial disease

      • Muscle atrophy

      • Hair loss

      • gangrene/ulcer

      • Shiny skin

      • Thickened toe nails

      • Swelling

    • Signs of venous disease

      • Spider veins

      • Reticular veins

      • Swelling

      • Varicose veins

      • Skin changes (eczema, lipodermatosclerosis, hemosiderin deposits)

      • Evidence of healed ulcers / active ulcers in Gaiter region of leg (lower medial calf)

      • “Inverted champagne bottle” legs

• Palpation

  • Abdominal aorta

    • above umbilicus

    • Normal = 2 cm wide

  • Temperature

    • Use back of hands

    • Palpate foot, tibia, knee, thigh

    • foot/leg/knee cooler than thigh

  • Capillary refill

    • Press nail of great toe until blanches and then release

    • Normal refill 3-4 seconds

  • Edema

    • Firmly push with thumb for at least 5 secs.

    • Check for indentation - pitting edema

    • Start over dorsum of foot, move proximally to medial malleolus, shin

  • Pulses

    • Dorsalis Pedis

      • Lateral to tendon of ext hallucis longus

    • Posterior Tibial

      • Posterior to medial malleolus

    • Popliteal

      • Popliteal space - with knee flexed

    • Femoral

      • Between ASIS and symphysis pubis

    • Grading: 0=none; 1+ diminished; 2+ normal; 3+ bounding

• Auscultation

  • • Bruits (use diaphragm)

      • Abdo aorta: midline, 2cm above umbilicus

      • Renal: 2 cm to either side of abdo aorta

      • Common iliac arteries: ½ way between umbilicus and ASIS

      • Femoral

• Special tests

  • Buerger’s test

    • Pallor on elevation

      • Pt supine

      • Elevate one leg and hold for 1 minute

      • Marked pallor may indicate arterial insufficiency

    • Rubor on dependency

      • After “pallor on elevation”

      • Gently drop leg over side of bed

      • Colour of plantar surface of foot

        • Should return to same colour of non-elevated leg within seconds

        • Rubor (marked redness) = arterial dilation in response to tissue hypoxia

• Post encounter questions:

  • What index may be abnormal, and raise suspicion for limb ischemia?

    • Ankle-brachial index (ABI)

      • BP at ankle / BP at brachial

      • Normal >0.9

  • Causes of pitting edema?

    • Systemic (heart, liver, kidney) or local disease

  • Causes of non-pitting edema?

    • Lymphatic dysfunction: LN dissection, lymphatic infiltration by malignancy or infection, hypothyroidism (myxedema)

  • List 3 signs/symptoms of acute leg pain due to arterial occlusion.

    • 6 Ps

      • Pain

      • Pallor

      • Parasthesia

      • Polar

      • Paralysis

      • Pulselessness

Rational Clinical exam:

• AAA (1999)

• Abdo Bruits (1995)

• DVT (1998)

• DVT (2006)

• Peripheral arterial disease (2006)