Introduction & General Features
1. Wash your hands, introduce yourself, and ask permission (consent) to examine. Always ask if the patient has any pain.
2. Obtain adequate exposure of the limb (ideally, trousers should be removed so the full lower limb can be visualised from groin downwards).
3. Step back and observe (eg. walking aids, amputated limbs, gangrenous extremities, ulcers, other trophic changes).
4. Hands: check the pulse (for Atrial Fibrillation (AF) - this can be a source of emboli, leading to ischaemia)
5. Neck: carotid pulses (character) & auscultate for bruits
6. +/- Heart (confirm the presence of AF if required)
Steps 5 & 6 do not always need to be performed. If you are, for example, asked to perform an examination of the vascular system of the patient's lower limbs, then checking the radial pulse will probably be adequate. If you find gangrenous toes, at the end of the examination you can mention to the examiner that you would like to examine the patient further for atrial fibrillation.
Inspection
Look carefully:
- Gently lift legs up & look at the underside (this can be easily missed)
- Look between the toes: scars / ulcers. Note that arterial ulcers have a 'sloughy' base and are punched out)
- Trophic (skin) changes: hair loss - 'glaborous', shiny appearance, venous guttering (when you raise the limbs and gravity empties the veins, their paths will appear to 'indent')
- Colour: dusky red or black (ischaemic), brownish eczematous/dry/thickened skin (venous disease - note that 'lipodermatosclerosis' needs to be palpated for by feeling for the hard thickened skin)
- Muscle bulk (check for symmetry)
- Other features: drains, wounds, amputated digits/limbs, etc.
Extras
To complete your examination:
Whilst you may not actually perform these remaining tests, make sure you know a bit about them, and in particular how they are performed, indications and complications. Mention to the examiner (at the end) that you would like to perform these to complete your examination of the peripheral vascular system.
- Buerger's test: Raise the limb as far as possible into the air (flex at the hip joint). Once the limb appears pale, get the patient to sit with the leg hanging off the side of the bed. Look for the ?sunset rubor? (dusky red colour) that the leg will take on as it refills. Record how long this takes. The dusky colour is due to reactive hyperaemia. Note that this can be painful for patients, so be gentle.
- Ankle-Brachial Pressure Index (ABPI): This is a ratio (normal=1.0) of the systolic BP at the ankle/the 'norma;' systolic BP at the arm. The brachial BP is measured as usual. To measure the ankle BP, place the cuff over the ankle as low as possible, whilst listening to the foot pulses using a Doppler probe. Note that you can obtain falsely high results in patients with diabetes due to the presence of vascular wall calcification. Generally, scores of >1.0 are normal, scores of 0.5-0.7 are compatible with intermittent claudication, and scores <0.4 are suggestive of critical limb ischaemia. A gangrenous limb will most likely have a score of 0.2 or below. In normal individuals, scores should not fall with exercise.
- Corridor walking test: Thus can be a useful and simple method of quantifying exactly what the patient can do (ie. the patient's functional ability).
- Doppler / duplex assessment: Doppler produces an audible waveform and duplex complements this with multi-coloured displays of the vascular flow, allowing a graphic representation of the flow patterns to be observed. These popular non-invasive techniques allow pressures to be recorded at different sites along the route of the vessels. Normal arterial waveforms are 'triphasic'. This becomes biphasic in the presence of arterial stenosis.
- Angiography (digital subtraction or CT): There are a number of complications associated with angiography. Spiral CT can provide detailed images of the entire vessel length.
