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Peripheral Vascular Examination

Discussion in 'General Practitioner' started by Ghada Ali youssef, Jan 13, 2017.

  1. Ghada Ali youssef

    Ghada Ali youssef Golden Member

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    Peripheral vascular examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs of peripheral vascular disease (PVD) using your examination skills. This peripheral vascular examination OSCE guide provides a clear step by step approach to examining the peripheral vasculature system, with an included video demonstration. Check out the peripheral vascular examination mark scheme here.

    Introduction
    • Wash hands
    • Introduce yourself
    • Confirm patient details – name / DOB
    • Explain examination
    • Gain consent
    • Ask if the patient currently has any pain
    General inspection
    • Is the patient comfortable at rest?
    • Look around bedside for treatments or adjuncts – mobility aids / O2 / cigarettes / medications
    • Obvious scars – may provide clues as to previous surgical procedures
    • Gross cyanosis / pallor of limbs
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    General inspection

    Upper body
    - Inspection

    • Colour – e.g. cyanosis / pallor
    • Tar staining – smoking is a risk factor for PVD
    • Tendon xanthomas – hypercholesterolemia
    • Gangrene – necrosis secondary to inadequate limb perfusion
    6b007482d8c581a4f87ed7559553869a.jpg
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    Inspect upper limbs

    - Palpation
    • Temperature if ↓ may indicate poor peripheral perfusion
    • Capillary refill timeshould be < 2 seconds
    - Pulses
    * RADIAL PULSE:

    • Assess rate and rhythm – palpate for at least 5 cardiac cycles
    • Assess for radio-radial delay – coarctation of the aorta
    * BRACHIAL PULSE –assess volume
    * BLOOD PRESSURE:

    • Record BP in both arms – significant difference may suggest aortic aneurysm
    • You’ll usually not be required to perform this during the OSCE
    • However ensure you acknowledge that you would ideally carry this out
    * CAROTID PULSE:
    • Auscultate for a bruit – if present avoid palpation due to risk of emboli
    • Medial to the sternocleidomastoid and beside the trachea
    • NEVER palpate both simultaneously
    • Auscultate for a bruit – may suggest stenosis at carotid bifurcation
    49a9e04fb5d57b30e709ca23f8263fc3.jpg
    Assess & compare limb temperature

    52997b233d045b7c24d9c5a70f45b856.jpg
    Assess capillary refill time

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    Palpate radial pulse

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    Assess for radio-radial delay

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    Palpate brachial pulse

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    Palpate carotid pulses

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    Auscultate carotid arteries

    Abdomen
    * AORTA – located in the midline of the epigastrium
    • Inspect the abdomen, looking for any obvious pulsation
    • Palpate either side of the aorta feeling for expansion – aneurysm
    • Auscultate for aortic bruits – suggestive of an aortic aneurysm
    fca2d3ab7198a9acd2a7c5185aecd220.jpg
    Palpate abdominal aorta

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    Auscultate abdominal aorta

    Lower limbs
    - Inspection " Compare the legs "
    • Scars – bypass surgery / vein harvest sites
    • Hair loss – PVD
    • Discolouration – e.g. necrosis
    • Pallor – suggests poor vascular perfusion
    • Missing limbs / toes – previous amputation
    • Ulcers – venous vs arterial – look between toes and lift feet up
    • Muscle wasting – may indicate PVD
    • Ask patient to wiggle their toes – gross motor assessment
    34590a48b87a0d20e50848825b5f61aa.jpg
    Inspect legs

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    Inspect posterior aspect of legs

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    Inspect between toes

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    Perform gross motor assessment

    - Palpation
    • Temperature – compare between the legs
    • Capillary refill time– < 2 seconds is normal – prolonged in PVD
    - PULSES
    " Work proximal to distal – this allows you to assess and compare inflow into each leg. If pulses are not palpable, a doppler can be used to assess blood flow through a vessel."

    * FEMORAL PULSE best palpated at the mid-inguinal point

    • The mid-inguinal point is located halfway between the anterior superior iliac spine and the pubic symphysis
    • Palpate to confirm its presence and assess volume
    • Assess for radio-femoral delay – suggestive of coarctation of the aorta
    • Auscultate to detect any bruits – femoral / iliac stenosis
    * POPLITEAL PULSEpalpated in the inferior region of the popliteal fossa
    • With the patient prone, flex the knee to 45º
    • Place your thumbs on the tibial tuberosity
    • Curl your fingers into the popliteal fossa to compress the popliteal artery against the tibia allowing you to feel its pulsation
    • This pulse is often difficult to palpate – NEVER lie and say you can feel it if you can’t. The popliteal artery is the deepest structure within the fossa, so the examiner will understand.
    • Auscultate to detect any bruits
    * POSTERIOR TIBIAL PULSE posterior to the medial malleolus of the tibia
    • Palpate to confirm its presence and compare pulse strength to the other foot
    * DORSALIS PEDIS PULSE dorsum of the foot
    • Lateral to the extensor hallucis longus tendon
    • Over the 2nd/3rd cuneiform bones
    • Palpate to confirm its presence and compare pulse strength to the other foot
    64ad27be58cdce9399fb5b6188782e51.jpg
    Assess & compare limb temperature

    5607a4ec644ee03ef095686e28a0a78e.jpg
    Assess capillary refill time

    424bc036de726e5d1c5b166e7946808a.jpg
    Palpate femoral pulse

    a8671d3aeb36e839c20feb745024efaf.jpg
    Auscultate femoral artery

    2946646723a58e14c7821f536d7b07dc.jpg
    Assess for radio-femoral delay

    c634941956cc3533c9985ba032931e7a.jpg
    Palpate popliteal pulse

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    Auscultate popliteal pulse

    21a36fab81410be0b1c16d74b234cf5e.jpg
    Palpate posterior tibial pulse

    b6637b37b9cdd2ad296ed50df89fa7f1.jpg
    Palpate dorsalis pedis pulse

    - Sensation
    " The aim when assessing sensation in this context is to identify limb paresthesia which can be a symptom of acute limb ischaemia."

    Perform a gross assessment of peripheral sensation:

    • Assess light touch sensation, starting distally
    • If intact distally, no further assessment is required
    • If reduced, assess to identify the extent paresthesia – e.g. whole limb / below knee / foot
    9c741dd292a9d9396b2fde8dc3e333e2.jpg
    Assess light touch sensation distally

    Buerger’s test
    " This test can be carried out to further demonstrate poor lower limb perfusion."

    1. Ensure the patient is positioned supine


    2. Standing at the bottom of the bed, raise both of the patient’s feet to 45º for 2-3 mins:
    • Observe for pallor – emptying of the superficial veins
    • If a limb develops pallor, note at what angle this occurs e.g. 20º (known as Buerger’s angle)
    • A healthy leg’s toes should remain pink, even at 90º
    • A Buerger’s angle of less than 20º indicates severe limb ischaemia
    3. Once the time limit has been reached, ask patient to place their legs over the side of the bed:
    • Observe for a reactive hyperaemia – this is where the leg first returns to its normal pink colour, then becomes red in colour – this is due to arteriolar dilatation (an attempt to remove built up metabolic waste)
    To complete the examination
    • Thank patient
    • Wash hands
    • Summarise findings
    Source
     

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