cmecde 632

 

33Cardiovascular and respiratory medicine

Station 14

Peripheral vascular system examination

In this station you may be asked to restrict your examination to the arterial or venous system only. You

must therefore be able to separate out the signs for either (see Table 6).

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• After checking for any pain, ask him to expose his feet and legs and to lie down on the couch.

The examination

Inspection

• General appearance: body habitus, missing limbs or digits, surrounding paraphernalia such as

walking aids, oxygen, cigarettes.

• Skin changes: pallor, shininess, loss of body hair, atrophie blanche (ivory-white areas), haemosiderin ­pigmentation, inflammation, eczema, lipodermatosclerosis.

• Thickened dystrophic nails.

• Scars.

• Signs of gangrene: blackened skin, nail infection, amputated toes.

• Venous and arterial ulcers. Remember to look in the interdigital spaces.

• Oedema.

• Varicose veins (ask the patient to stand up). Varicose veins are often associated with incompetent valves in the long and short saphenous veins.

Do not make the common mistake of asking the patient to stand up before having

examined for varicose veins.

Palpation and special tests

• Ask about any pain in the legs and feet.

• Assess skin temperature by running the back of your hand along the leg and the sole of the

foot. Compare both legs.

• Capillary refill. Compress a nail bed for 5 seconds and let go. It should take less than 2 seconds

for the nail bed to return to its normal colour.

• Peripheral pulses (compare both sides).

– femoral pulse at the inguinal ligament

– popliteal pulse in the popliteal space (flex the knee)

– posterior tibial pulse behind the medial malleolus

– dorsalis pedis pulse over the dorsum of the foot, just lateral to the extensor tendon of the

great toe

• Buerger’s test:

– lift both of the patient’s legs to a 15 degree angle and note any collapse of the veins (‘venous

guttering’), which is indicative of arterial insufficiency

– lift both of the patient’s legs up to the point where they turn white (this is Buerger’s angle);

if there is no arterial insufficiency, the legs will not turn white, not even at a 90 degree angle

Clinical Skills for OSCEs

34 Station 14 Peripheral vascular system examination

– ask the patient to dangle his legs over the edge of the couch; in chronic limb ischaemia,

rather than returning to its normal colour, the skin will slowly turn red like a cooked lobster

(reactive hyperaemia)

• Oedema. Firm ‘non-pitting’ oedema is a sign of chronic venous insufficiency (compare to the

‘pitting’ oedema of cardiac failure).

• Varicose veins. Tenderness on palpation suggests thrombophlebitis.

• Trendelenburg’s test:

– elevate the leg to 90 degrees to drain the veins of blood

– occlude the sapheno-femoral junction (SFJ) with two fingers

– keep your fingers in place and ask the patient to stand up

– remove your fingers: if the superficial veins refill, this indicates incompetence at the SFJ

• Tourniquet test:

– elevate the leg to 90 degrees to drain the veins of blood

– apply a tourniquet to the upper thigh

– ask the patient to stand up: if the superficial veins below the tourniquet refill, this indicates

incompetent perforators below the tourniquet

– release the tourniquet: sudden additional filling of the veins is a sign of sapheno-femoral

incompetence

[Note] The tourniquet test can be repeated further and further down the leg, until the superficial veins below the

tourniquet no longer refill.

Auscultation

• Femoral arteries.

• Abdominal aorta.

• Renal arteries.

After the examination

• Thank the patient.

• Ensure that he is comfortable.

• Summarise your findings and offer a differential diagnosis.

• If appropriate, indicate that you might also measure the ABPI (see Station 15) and examine the

cardiovascular system and abdomen (aortic aneurysm).

Cardiovascular and respiratory medicine

Station 14 Peripheral vascular system examination 35

Table 6. Examination of the arterial or venous system only

Arterial system Venous system

Pallor

Shininess

Dystrophic nails

Loss of body hair

Arterial ulcers

Signs of gangrene

Skin temperature

Capillary refill

Peripheral pulses

Buerger’s test

Auscultation of femoral arteries and aorta

ABPI (if time permits, see Station 15)

Atrophie blanche

Pigmentation

Inflammation

Eczema

Lipodermatosclerosis