- Peripheral Vascular Physical Exam
Inspection
Arms
- Ensure proper draping, allowing inspection from the shoulders to the fingertips or both arms.
- Take special note of:
- Size and symmetry of both arms
- Edema
- Venous pattern or distension
- Colour and texture of the skin and nail beds
- Nicotine stains
- Raynaud’s disease: affected areas (fingertips) can turn white or blue due to insufficient blood flow to distal arteries
- Clubbing
- Skin chatacteristics
- Rashes, ulcers, or scars
- Petechiae or purpura
- Hair distribution
- Muscle Atrophy
Legs
- Ensure proper draping, allowing full inspection of the legs from the groin to the tips of the toes while covering the external genitalia.
- Inspect the legs and buttocks from the groin to the feet taking note of:
- Size and symmetry of both legs
- Edema
- Venous pattern or distension
- Colour and texture of the skin and nail beds
- Abnormally pale, red or blue foot for PVD
- Sensitivity 35%, Specificity 87%
- LR+ 2.8 and LR- 0.7
- Skin chatacteristics
- Rashes, ulcers, or scars
- Petechiae or purpura
- Hair distribution
- Presence of atraumatic wounds or sores on the foot for PVD
- Sensitivity 2% and specificity 100%
- LR+ 7.0 and LR- NS
- Hemosiderin deposition
- Clubbing
- Muscle atrophy
Palpation
Axial
- Palpate carotid pulse bilaterally, noting:
- Rate
- Rhythm
- Amplitude and any variations in amplitude
- Timing of upstroke in relation to S1 and S2
- Presence of thrills (if present, auscultate for bruit)
- Palpate the abdominal aorta noting its size
Arms
- Feel the temperature of the arms and hands, comparing one side to the other.
- Test capillary refill
- Average time is 2-3 seconds
- Palpate the following pulses in each arm, noting any differences between the two sides:
- Brachial Pulse: Brachial artery at the bend of the elbow, just medial to the biceps tendon
- Radial Pulse: Radial artery on lateral flexor surface near the wrist.
- Consider grading the pulses on a scale:
- 0 = Absent or unable to palpate.
- 1+ = Weak or diminished pulse.
- 2+ = Brisk, pulse is as expected.
- 3+ = Bounding pulse.
- Palpate for epitrochlear nodes between the biceps and triceps muscles
- Flex patient's arm to 90° for better access
- Enlarged node may be indicative of insufficient drainage
- Consider doing an Allen’s Test
Legs
- Feel the temperature of the legs and feet, comparing one side to the other.
- Asymmetrically cooler foot in PVD.
- Sensitivity 10% and Specificity 98%
- LR+ 6.1 and LR- 0.9
- Test capillary refill
- Average time is 2-3 seconds
- Capillary refill time of equal to or greater than 5 seconds in the great toe is indicative of PVD
- Sensitivity 28% and specificity 85%
- LR+ 1.0 and LR- NS
- Check for pitting edema
- Press firmly with your thumb for at least five seconds in the following locations of each lower extremity:
- The dorsum of each foot
- Behind the medial malleolus
- Over the shins
- Note the presence, degree of pitting (depression formation) and the most proximal point of edema (e.g. extending to the knees) to identify the location of possible occlusion
- Grade the edema on a 4 point scale:
- From slight (1+) to very marked (4+)
- No pitting is normal
- Consider taking a measurement of the edematous legs:
- Useful to compare one leg to the other, and the same limb to itself at various time points
- Difference >1cm near ankle or >2cm at calf suggests edema
- Using a measuring tape, obtain circumference from:
- The forefoot
- Smallest possible circumference near the ankle
- Largest calf circumference
- Midthigh with knee extended and measured upward from patella
- Evaluate veins
- Palpate femoral vein and veins of the calf
- Note any abnormalities, including:
- Tenderness suggestive of deep vein thrombosis
- Prominence or distension for venous etiology of edema
- Cords
- Palpate the following pulses in each leg, noting any differences between the two sides:
- Femoral pulse: Femoral artery in groin region, approximately below the mid-point of the inguinal ligament
- Absent femoral pulses in PVD
- Sensitivity and specificity for peripheral vascular disease have been found to be 7% and 99%, respectively
- LR+ 6.1 and LR- NS
- Popliteal pulse: Popliteal artery as it passes posterior to the knee in the popliteal fossa
- Effectively found by laying the patient supine and holding the knee slightly flexed, with both fingertips lightly in the fossa
- Dorsalis pedis pulse: Dorsalis pedis artery on dorsal surface of the foot, lateral to the extensor hallucis longus tendon
- Posterior tibial pulse: Posterior tibial artery as it passes just posterior and inferior to the medial mallelous
- Absent dorsalis pedis and posterior tibial pulses in PVD
- Sensitivity 63-72% and specificity 92-99%
- LR+14.9 and LR- 0.3 (Best screening for PVD)
- Consider grading the pulses on a scale
- 0 = Absent or unable to palpate.
- 1+ = Weak or diminished pulse.
- 2+ = Brisk, pulse is as expected.
- 3+ = Bounding pulse.
- In general:
- Weakened/absent pulse in occlusion proximal to this site
- Exaggerated/widened pulse in aneurysm
- Consider performing a diabetic foot exam
- Consider mapping varicose veins
- Consider performing a Buerger's test
- To evaluate the competency of the valves of the venous system consider completing a Trendelenburg Test
Auscultation
- Using the diaphragm of a stethoscope, listen to the carotid arteries for a bruit.
- Especially if the patient is middle aged, elderly, or cerebrovascular disease is suspected
- Breath sounds may obscure proper carotid auscultation
- Auscultation of the carotid arteries may also reveal severe, radiating heart murmurs
- Using the diaphragm of the stethoscope, listen for bruits over the aorta, renal arteries, iliac arteries, and femoral arteries.
- Note whether the bruit occurs only during systole or if it has both systolic and diastolic components.
- Presence of bruit for PVD
- Sensitivity 20-50% and specificity 95-99%
- LR+ 7.3 and LR- 0.7
Clinical Usefulness
Clinical findings suggestive of PVD
Inspection
- Wounds or sores on foot
- Foot colour abnormally pale, red or blue
Palpation
- Foot asymmetrically cooler
Absent femoral pulse
Absent posterior tibial and dorsals pedis pulses
Auscultation
References
- Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
- Bitar R, Jugovic P, McAdam, L. Fundamental Clinical Situations: A Practical OSCE Study Guide 4th Edition. Toronto, ON, Canada: Elsevier Canada; 2004.
- Filate, W, Leung, R, Ng, D, Sinyor, M. Essentials of Clinical Examination Handbook 5th Edition. Toronto, ON, Canada: The Medical Society Faculty of Medicine University of Toronto; 2005.
- McGee S. Evidence-Based Physical Diagnosis. Philadelphia, PA: Saunders, 2001.