Peripheral vascular examination

Question 1

Examination of the abdominal vascular system

Answer 1

Inspection

• scars (aorto-bifemoral bypass surgery, open aortic aneurysm)
• look for visible pulsations - pulsation normally aorta is visible unless patient is obese

Palpation

• Aorta: with the patient relaxed, palpate bimanually in the epigastrum, lies close to midline and bifurcates at the umbillicus
  
  • aneurysm is pulsatile and laterally exanisle
  • swellings that are pulsatile bbut not expansile can be an artery lying above an underlying mass
  • estimate size
• iliac arteries

Ausculatation

• auscultate in teh epigastrium, over the aortic bifurcation and over both iliacs
• listen for bruits

Question 2

Lower limb inspection

Answer 2

• colour: pallor, red, mottled
• scars - femoral-popliteal bypass. femoro- distal bypass
• Trophic changes: thin shiny skin, hair loss, thickened/ distoreted nails - chronic ischaemia
• tissue loss: necrosis or gangrene - critical limb ischaemia
• ulceration: see next card - check between toes and pressure points- heel, malleoli, 1st metatarsal head and lateral side of foot
  
  • if present asses site, size, edge, depth, exudates
• venous guttering

Question 3

Arterial ulcer

• site
• lesion characteristic
• associated signs

Answer 3

• site -
  
  • ​pressure sites/ trauma
  • pretibial
  • lateral mallelous
  • balls of foot
  • toe tups
  • between toes
• lesion characteristics
  
  • ​well defined, small, deep
  • punched out edges
  • necrotic base
• Associated signs
  
  • trophic skin changes, pallor, cold skin, poor capillary refill time, weak/ absent pulses, positive buergers test

Question 4

Venous ulcer

• site
• lesion
• characteristc

Answer 4

site - medial gator area (medial mallelus)

Lesion characteristics

• irregular, large, shallow ulcers
• sloping edges
• exudative or granulating bases

Characteristics

• signs of chronic venous insuffiency: oedema, venous eczema, haemosiferosis, atrophie blanche, lipodermatoscerlosis

Question 5

Neuropathic ulcer

• Site
• lesion characteristics
• associated signs

Answer 5

Site

• pressure areas - heels, soles, metatarsal heads

Lesion characteristics

• variable size and depth
• callelous edges
• granulating base

Associated signs

• peripheral neuropathy
• normal peripheral pulses

Question 6

Lower limb Palpation

Answer 6

• Temperature - run the back of hand one at a time down the limb and compare - cold indicated PAD
• Caoillary refilll time - tip of toe for five seconds
• Pulses - move from one side to the other comparing both sides
  
  • Femoral- located at the mid-inguinal point (halfway between teh ASIS and pubic symphysis)
  • popliteal - use both hands. Flex the knee slightly placing both thumbs on the tibial tuberosity to counter pressure and press the eigh fingertipls firminly in the popliteal fossa to feel the pulse
  • posterior tibial - located halfway along the line between the heel and the medial mallelus
  • dorsalis pedis- located just lateral to the extensor hallucis longus tendon in the cleft between teh first two metatarsals (10% not palpable)
    *

Question 7

Ausculation lower limb

Answer 7

listen for bruits over:

• femoral pulse
• adductor hiatus

Question 8

Buergers test

Answer 8

• postiive patient supine
• raise the legs to 45 degrees for a minute
• look for pallor + venous guttering
• ask the patient to sit up and dangle legs over the edge of the bed. note the time it takes for foot to regain colour

Positive - pallor + venous guttering on elevation followed by dusky red colour on dependency - severe ischaemia

Question 9

Buergers angle

Answer 9

the angle from hirizontal at which the leg turns pale

normally >90o

the shallower the angle the more severe the peripheral arterial disease