Arterial vascular examination (upper and lower limb)

Upper and lower limb arterial examination and questions for medical student exams, finals, OSCEs and MRCP PACES

Intro (WIIPPPPE)

Treatments:
- Oxygen therapy (method of delivery and rate)
- GTN spray
- Insulin pen
- IV infusions
Paraphernalia:
- Wheelchair or walking aids
- Food and drink
- Cigarettes/ nicotine patches/ gum

Upper limbs
- Inspect
  - Colour (peripheral cyanosis/ mottled discolouration)
  - Cigarette tar staining (not nicotine!)
  - Blood glucose testing on fingertips
  - Tendon xanthomata (hyperlipidaemia)
  - Scars (radial artery harvest for CABG, wrist scars from angiography/ interventional radiology)
  - Subclavian artery aneurysm
- Palpate
  - Temperature
  - Gross sensation (distal to proximal)
  - Capillary refill (at level of heart, both limbs, normal <2s)
  - Radial pulse (rate, rhythm)
  - Radio-radial delay
    - Aortic dissection
    - Aortic coarctation (delayed on left depending on level of coarctation)
    - Subclavian artery stenosis
  - Radio-femoral delay
    - Aortic coarctation
  - Brachial pulse [only necessary if you fail to feel a radial pulse]
  - Ask for blood pressure in both arms. Unequal BPs suggest:
    - Aortic dissection (BP reduced on left depending on level of dissection)
    - Subclavian artery stenosis (BP reduced on side of stenosis)
    - Aortic coarctation (BP reduced on left depending on level of coarctation)
  - Carotid pulse
- Auscultate
  - Carotid bruits

Peripheral vascular exam video

Abdomen
- Inspect (at level of patient)
  - Scars: midline laparotomy or T shaped scar (suggests emergency AAA repair)
  - Pulsatile aorta
- Palpate
  - Aorta (above umbilicus): Pulsatile AND expansile? Approximate diameter?
    - The aorta should be pulsatile but should not be expansile.
  - Auscultate
    - Aortic bruit (above umbilicus)
    - Renal bruits

Lower limbs
- Inspect
  - Colour: peripheral cyanosis/ mottled discolouration
  - Skin: shiny or hairless
  - Scars
    - Long saphenous vein harvesting for CABG
    - Groin scars from angiography/ interventional radiology/ EVAR/ angioplasty/catheter-directed thrombolysis
  - Ulcers
    - Arterial ulcer sites: dorsum of foot, between toes, tips of toes
    - Diabetic ulcer sites: pressure points (heel, metatarsal heads)
- Palpate
  - Temperature
  - Gross sensation (distal to proximal)
  - Capillary refill
  - Femoral pulses: mid-inguinal point, halfway between ASIS and pubic symphysis
  - Radio-femoral delay (if not already done)
  - Popliteal pulses
    - 10% of patients with popliteal aneurysm have an AAA
    - 30% of patients with AAA have a popliteal aneurysm
  - Dorsalis pedis (lateral to tendon of extensor hallucis longus)
    - Absent in 10% of normal people
  - Posterior tibial pulses (2cm below and behind medial malleolus)
- Auscultate
  - Femoral bruits

Thank patient, ensure they’re comfortable and ask if they need any help in getting dressed
Wash hands
Turn to examiner, hands behind back, holding stethoscope, before saying: “To complete my examination, I would like to…”
- Further examinations:
  - Perform a full cardiovascular examination
  - Perform neurological and venous examination of the upper and lower limb
  - Special test: perform Buerger’s test if indicated
- Bedside investigations:
  - Ankle-Brachial Pressure Index (ABPI)
  - Measure claudication distance and total walking distance
  - 12-lead ECG
  - Capillary blood glucose
  - Fundoscopy (for hypertensive and diabetic retinopathy)
- Further investigations:
  - Bloods (FBC, U&Es, lipids, ESR/CRP, glucose and HbA1c, thrombophilia screen if indicated)
  - Arterial duplex
  - Angiography