Peripheral Vascular OSCE Examination

1. Introduction
2. General Inspection
3. Upper Limb – Hands and Arms
4. Face, Eyes and Mouth
5. Carotid Pulse
6. Abdomen – Abdominal Aorta
7. Lower Limb Inspection
8. Temperature and Capillary Refill
9. Lower Limb Pulses
10. Auscultation
11. Buerger’s Test
12. Sensation and Movement
13. Completing the Examination
14. Quiz

Wash your hands thoroughly before approaching the patient.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail.

Ask the patient if they are currently in any pain, particularly in the legs or feet, as patients with severe ischaemia may have rest pain and the examination involves handling the limbs.

Position the patient lying supine (flat) on the bed, ideally with the head supported on one pillow. Lying flat is important because the later Buerger’s test relies on raising the legs from a level starting position.

Expose the patient appropriately from the waist down, leaving the underwear in place. Adequate exposure of both legs is essential so that the limbs can be compared directly, and the arms should also be accessible for the upper limb assessment.

Begin by standing back and observing the patient and their surroundings. Look at the patient’s general state: do they appear comfortable or are they in distress or pain? A patient with critical limb ischaemia may hang the affected leg out of the bed, as the dependent position improves perfusion and eases rest pain.

Look around the bedside for clues. Cigarettes or nicotine replacement are highly relevant, as smoking is the single most important modifiable risk factor for peripheral arterial disease. A wheelchair, walking aids or a visible prosthetic limb may suggest reduced mobility or previous amputation due to critical ischaemia. Look for diabetic equipment such as blood glucose monitors or insulin, as diabetes is a major risk factor for PAD and for diabetic foot disease.

Although peripheral vascular disease classically affects the lower limbs, the examination conventionally begins with the hands, as they offer evidence of overall cardiovascular risk and arterial supply to the upper limb.

Inspect the hands for tar staining on the fingers, which is a marker of smoking and therefore of vascular risk. Look for peripheral cyanosis (a bluish tinge to the fingertips) reflecting poor peripheral perfusion, and for any signs of tissue loss at the fingertips such as ulceration or gangrene, which can occur in severe upper limb arterial disease or vasospastic conditions. Note any tendon xanthomata – firm, yellow cholesterol deposits over the extensor tendons or knuckles – as these point to hyperlipidaemia and a heightened atherosclerotic risk.

Assess the temperature of both hands with the back of your fingers, comparing one side with the other. Symmetrically warm hands suggest adequate perfusion, whereas a cool, pale hand suggests impaired arterial supply.

Measure the capillary refill time by pressing on a fingertip (or nail bed) for five seconds and then releasing. The skin should return from white to its normal colour in less than two seconds. A prolonged capillary refill suggests poor peripheral perfusion.

Palpate the radial pulse, assessing its rate and rhythm. A normal resting rate is around 60–100 bpm. An irregularly irregular pulse suggests atrial fibrillation, which is important here because AF is a major source of emboli that can cause acute limb ischaemia.

Palpate both radial pulses simultaneously to check for radio-radial delay. A delay between the two pulses can be caused by subclavian artery stenosis, aortic dissection or coarctation of the aorta, all of which obstruct or alter flow to one arm.

Palpate the brachial pulse at the antecubital fossa, just medial to the biceps tendon, to assess a larger, more central pulse and gain a better sense of its volume and character than the radial allows. The brachial artery is also the vessel used when recording the blood pressure.

State that you would measure the blood pressure in both arms. Hypertension is a key risk factor for atherosclerosis, and a significant difference between the arms can again point towards subclavian stenosis or aortic dissection.

Briefly inspect the face for signs of associated cardiovascular risk. Around the eyes, look for corneal arcus (a pale ring around the iris) and xanthelasma (raised yellow plaques on the eyelids), both of which reflect hyperlipidaemia and therefore an increased risk of atherosclerotic disease.

Ask the patient to gently pull down a lower eyelid and inspect the conjunctiva for pallor, which suggests anaemia. Anaemia is relevant because it reduces oxygen delivery and can worsen symptoms of an already poorly perfused limb.

Inspect the inside of the mouth for central cyanosis, seen as a bluish tinge to the tongue and mucous membranes, which indicates low arterial oxygen saturation. Poor dentition is also worth noting as a potential source of bacteraemia.

Palpate the carotid pulse by placing your fingers gently between the larynx and the anterior border of the sternocleidomastoid muscle. Assess the volume and character of the pulse. A slow-rising pulse may suggest aortic stenosis, while the carotid gives a useful impression of central pulse character.

Only ever palpate one carotid at a time. Pressing on both simultaneously risks critically reducing cerebral blood flow, and firm pressure can stimulate the carotid sinus, causing a reflex drop in heart rate and blood pressure that may make the patient faint.

Using the diaphragm of your stethoscope, auscultate over each carotid artery while the patient holds their breath, listening for a bruit. A bruit is a whooshing sound produced by turbulent flow through a narrowed artery and is a sign of carotid atherosclerosis, which carries an increased risk of stroke. (Note that a murmur from aortic stenosis can radiate to the neck and mimic a bruit.)

Inspect the abdomen, looking in the midline of the epigastrium for any obvious pulsation. A prominent, visible pulsation may suggest an abdominal aortic aneurysm (AAA), although it can be normal in a slim patient.

Palpate the abdominal aorta by placing a hand on either side of the midline just above the umbilicus. In a normal aorta your hands will be pushed upwards with each pulsation. If your hands are pushed outwards (away from each other) as well, this suggests an expansile, pulsatile mass consistent with an AAA. This distinction matters because aneurysms are at risk of rupture, a surgical emergency.

Auscultate just above and to the side of the umbilicus for aortic and renal bruits, which indicate turbulent flow through a narrowed aorta or renal arteries.

The lower limbs are the focus of the examination. Inspect both legs together so that you can directly compare one side with the other, looking at the whole limb from the groin down to the toes, and remembering to inspect between the toes and the soles of the feet, where ulcers are easily missed.

Look at the colour of the limbs. Pallor (pale skin) suggests poor arterial perfusion. Ischaemic rubor is a dusky, red-purple discolouration that develops when the leg is hanging down (dependent); it occurs because chronic ischaemia causes loss of capillary tone, so the dilated capillaries fill with stagnant, deoxygenated blood.

Look for trophic skin changes caused by chronically reduced perfusion. These include hair loss over the legs and feet, shiny, thin skin, and brittle, slow-growing nails. The tissues are simply not receiving enough blood to maintain their normal structures.

Inspect carefully for arterial ulcers. These are typically found at the most peripheral and pressure-prone sites – the tips of the toes, the heels and over bony prominences such as the lateral malleolus. They are classically small, sharply defined with a ‘punched-out’ appearance, deep, and painful. This contrasts with venous ulcers, which are usually larger, shallow and found around the medial malleolus (the ‘gaiter’ area).

Image - An arterial ulcer in a patient with peripheral vascular disease. Arterial ulcers are typically deep, ‘punched-out’ and painful, and occur at the most peripheral, pressure-bearing sites

Creative commons source by Jonathan Moore [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)]

Look for gangrene, which is tissue necrosis (death) due to a critical lack of perfusion. Dry gangrene appears as black, mummified, dry tissue, most often at the toes, and represents end-stage critical limb ischaemia. Note any missing toes or limbs, which indicate previous amputation for critical ischaemia or diabetic foot disease. Finally, look for any surgical scars – for example a long scar down the inner thigh and leg may indicate a previous bypass graft, and a scar in the groin or abdomen may suggest previous vascular surgery.

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