Peripheral Vascular OSCE Examination

Contents

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

Introduction

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.

General Inspection

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.

Upper Limb – Hands and Arms

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.

Face, Eyes and Mouth

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.

Carotid Pulse

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.)

Abdomen – Abdominal Aorta

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.

Lower Limb Inspection

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.

Temperature and Capillary Refill

Using the back of your fingers, assess and compare the temperature of both legs, working from proximal to distal. A limb that becomes progressively cooler towards the foot, or one leg that is colder than the other, suggests reduced arterial inflow. The level at which the temperature changes can give a rough indication of where the arterial narrowing or occlusion lies.

Assess the capillary refill time at the toes or nail beds by applying five seconds of pressure and then releasing. A refill time of more than two seconds suggests poor peripheral perfusion, consistent with arterial disease.

Lower Limb Pulses

Palpate the lower limb pulses systematically, always working from proximal to distal. This allows you to assess and compare the arterial inflow into each leg and to localise the level of any disease – pulses will be diminished or absent below the level of an obstruction.

• Femoral pulse – palpated at the mid-inguinal point, halfway between the anterior superior iliac spine and the pubic symphysis. This assesses inflow from the aorto-iliac segment.
• Popliteal pulse – felt deep in the popliteal fossa behind the knee, with the knee slightly flexed and relaxed, using the fingertips of both hands to press the artery against the back of the tibia. It is normally difficult to feel even in healthy people, so a prominent or easily palpable popliteal pulse should raise suspicion of a popliteal aneurysm (a pulsatile mass behind the knee). Both popliteal fossae should be examined, as popliteal aneurysms are frequently bilateral and may co-exist with an abdominal aortic aneurysm.
• Posterior tibial pulse – felt just behind and below the medial malleolus.
• Dorsalis pedis pulse – felt on the dorsum of the foot, lateral to the extensor hallucis longus tendon.

Image - The posterior tibial pulse is palpated just behind and below the medial malleolus (the bony prominence on the inner ankle)

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Image - The dorsalis pedis pulse is felt on the dorsum of the foot, lateral to the tendon of extensor hallucis longus

SimpleMed original

Always compare each pulse with the same pulse on the opposite leg. The absence of one or more of these pulses is a key sign of peripheral arterial disease, and the level at which pulses disappear helps localise the disease – for example an absent femoral pulse points to aorto-iliac disease, whereas present femoral but absent foot pulses suggest more distal (femoro-popliteal) disease. If a foot pulse cannot be felt, state that you would confirm whether flow is present using a hand-held Doppler. Note also that the dorsalis pedis pulse is congenitally absent in a small proportion of healthy individuals, so it should always be interpreted alongside the other findings.

Palpate the femoral and radial pulses simultaneously to assess for radio-femoral delay. In a healthy person these pulses are felt at the same time. A delay between them suggests coarctation of the aorta, where narrowing of the aorta delays blood flow to the lower body.

Auscultation

Using the diaphragm of your stethoscope, auscultate over the femoral pulse in each groin, listening for a bruit. A femoral bruit indicates turbulent flow through a narrowed artery and suggests aorto-iliac or femoral stenosis.

It is good practice to also state that you would auscultate over the abdominal aorta (if not already done) and the carotid arteries for bruits, as atherosclerosis is rarely confined to a single vessel and finding disease in one territory should prompt assessment of the others.

Buerger’s Test

Buerger’s test is a two-part manoeuvre used to assess the adequacy of the arterial supply to the leg. It is one of the most informative bedside tests for peripheral arterial disease.

Part one – elevation. With the patient lying supine, stand at the foot of the bed and slowly raise both of the patient’s legs together, supporting them at the heels and watching the colour of the feet as you go. In practice the legs are commonly raised to around 45° and held there for one to two minutes to allow any colour change to develop, but you should note the exact angle at which a change occurs. In a healthy limb the foot stays pink even when elevated to 90° or beyond. In an ischaemic limb the foot develops pallor (and the superficial veins may collapse, or ‘gutter’), because the arterial pressure is no longer high enough to push blood up against gravity. The angle at which the leg goes pale is called Buerger’s angle, and a lower angle means more severe disease: a Buerger’s angle of less than 20° indicates severe ischaemia, whereas a healthy leg has an angle of 90° or more.

Part two – dependency. Next, sit the patient up and ask them to hang their legs down over the side of the bed. In a healthy limb the colour returns to normal within a few seconds. In an ischaemic limb you see a characteristic sequence: the foot first turns blue (as the slow-moving blood becomes deoxygenated), then a dusky red (sometimes called the ‘sunset foot’). This redness is reactive hyperaemia – the ischaemic, hypoxic tissue has caused the arterioles to dilate, so when blood finally returns under gravity the dilated vessels flood with blood, producing the deep red colour. A positive Buerger’s test is a strong indicator of significant peripheral arterial disease.

Sensation and Movement

Perform a gross assessment of sensation in both feet, for example by lightly touching the patient and asking whether it feels normal and the same on both sides. Also make a quick gross assessment of power and movement by asking the patient to wiggle their toes and move their feet, since weakness can signal advanced ischaemia.

This is important for two reasons. Firstly, acute limb ischaemia classically presents with the ‘six Ps’ – pain, pallor, pulselessness, perishingly cold, paraesthesia (altered sensation) and paralysis – and the development of sensory or motor loss is a sign of a limb-threatening emergency requiring urgent vascular intervention. Secondly, many patients with PAD also have diabetes and an associated peripheral neuropathy, which causes a ‘glove and stocking’ loss of sensation. This neuropathy means painless foot ulcers can develop and progress unnoticed, so identifying it is an important part of assessing the patient’s overall risk.

Completing the Examination

Thank the patient and ensure they are comfortable and re-covered, then wash your hands.

Summarise your findings clearly.

To complete the examination, state that you would:

• Measure the ankle-brachial pressure index (ABPI) using a hand-held Doppler – the ratio of the highest ankle systolic pressure to the highest brachial systolic pressure. A normal ABPI is around 0.9–1.2; a value below 0.9 suggests peripheral arterial disease, and a value below 0.5 suggests severe disease or critical limb ischaemia. Be aware that calcified, incompressible arteries (as in diabetes) can give a falsely elevated ABPI.
• Perform a full cardiovascular examination and assess the other vascular territories, given that atherosclerosis is a systemic disease.
• Examine the diabetic foot in detail and perform a neurological examination of the lower limbs where relevant.
• Take a focused history, including intermittent claudication (cramping leg pain on walking that is relieved by rest) and rest pain, and document cardiovascular risk factors.
• Arrange relevant investigations, such as blood tests (glucose/HbA1c, lipid profile, full blood count and renal function), an ECG, and imaging such as arterial duplex ultrasound or CT/MR angiography to localise and grade any stenosis.

Quiz

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