Peripheral vascular examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This peripheral vascular examination OSCE guide provides a clear concise, step by step approach to examining the peripheral vasculature system, with an included video demonstration.

Introduction

Wash hands
Introduce yourself
Confirm patient details
Explain examination
Gain consent
Ask if patient has any pain anywhere before you begin!

General inspection

Comfortable at rest?
Look around bedside for treatments or adjunctsmobility aids / O2 / cigarettes / medications
Obvious scars - may provide clues as to previous surgical procedures
Cyanosis / pallor of limbs 

  • General inspection
Upper body
Inspection

Colour - e.g. cyanosis / pallor
Tar staining - smoking is a risk factor for PVD
Tendon xanthomahypercholesterolemia
Gangrene – necrosis secondary to inadequate limb perfusion

  • Inspect upper limbs
Palpation

Temperature - if ↓ may indicate poor peripheral perfusion

Capillary refillshould be < 2 seconds

 

PULSES

RADIAL PULSE:

  • Assess rate & rhythm – palpate for at least 5 cardiac cycles
  • Assess for radio-radial delay suggestive of Coarctation of the aorta

 

BRACHIAL PULSE - assess volume

 

BLOOD PRESSURE:

  • Record BP in both arms - significant difference may indicate aortic aneurysm
  • You’ll usually not be required to perform this during the OSCE (due to time constraints)
  • However ensure you acknowledge that you would ideally carry this out

 

CAROTID PULSE:

  • Medial to the sternocleidomastoid & beside the trachea
  • NEVER palpate both simultaneously
  • Auscultate for a bruit - may suggest stenosis at carotid bifurcation
  • Assess & compare limb temperature
Abdomen

AORTA – located in the midline of the epigastrium

  • Inspect the abdomen, looking for any obvious pulsation
  • Palpate either side of the aorta feeling for expansion –  aneurysm
  • Auscultate for aortic bruits –  suggestive of an aortic aneurysm
  • Palpate abdominal aorta
Lower limbs
Inspection

Compare the legs 
Scars - bypass surgery / vein harvest sites (great saphenous vein)
Hair loss - PVD
Discolouration - e.g. haemosiderin staining (sign of venous disease – not PVD)
Pallor – suggests poor vascular perfusion
Missing limbs / toes –  previous amputation
Ulcers - venous vs arterial – look between toes and lift feet up
Muscle wasting – may indicate PVD
Ask patient to wiggle their toes – gross motor assessment

  • Inspect legs
Palpation

Temperature – compare the legs
Capillary refill-  < 2 seconds is normal - prolongation suggestive of PVD

 

PULSES

Work proximal to distal – this allows you to assess & compare inflow into each leg
If pulses are not palpable, a doppler can be used to assess blood flow through a vessel

 

FEMORAL PULSE - best palpated at the mid inguinal point 

  • The mid inguinal point is located halfway between the ASIS & the pubic symphysis 
  • Palpate to confirm its presence & assess volume
  • Assess for radio-femoral delay – suggestive of coarctation of the aorta
  • Auscultate to detect any bruitsfemoral / iliac stenosis

 

POPLITEAL PULSE – palpated in the inferior region of the popliteal fossa

  • With the patient prone, flex the knee to 45º
  • Place your thumbs on the tibial tuberosity
  • Curl your fingers into the popliteal fossa to compress the popliteal artery against the tibia allowing you to feel its pulsation
  • This pulse is often difficult to palpate – NEVER lie and say you can feel it if you can’t, instead be honest, the popliteal artery is the deepest structure within the fossa, so the examiner will understand. If this does happen, simply move on to assessing pedal pulses.

 

POSTERIOR TIBIAL PULSE – posterior to the medial malleolus of the tibia

  • Palpate to confirm it’s presence & compare pulse strength to the other foot

 

DORSALIS PEDIS PULSE – dorsum of the foot

  • Lateral to the extensor hallucis longus tendon 
  • Over the 2/3rd cuneiform bones
  • Palpate to confirm it’s presence & compare pulse strength to the other foot
  • Assess & compare limb temperature
Sensation

The aim when assessing sensation in this context is to identify limb paresthesia which can be a symptom of acute limb ischaemia.

Perform a gross assessment of peripheral sensation:

  • Assess light touch sensation, starting distally
  • If intact distally, no further assessment is required
  • If reduced, assess to identify the extent paresthesia - e.g. whole limb / below knee / foot
  • Assess light touch sensation distally
Buerger’s test

This test could be carried out to further demonstrate poor lower limb perfusion

1. Ensure the patient is positioned supine

 

2. Standing at the bottom of the bed, raise both of the patients feet to 45º for 2-3 mins:

  • Observe for pallor – emptying of the superficial veins 
  • If a limb develops pallor, note at what angle this occurs e.g. 20º (known as Buerger’s angle)
  • A healthy legs toes should remain pink, even at 90º
  • A Buerger’s angle of less than 20º indicates severe limb ischaemia

 

3. Once the time limit has been reached, ask patient to place their legs over the side of the bed:

  • Observe for a reactive hyperaemiathis is where the leg first returns to its normal pink colour, then becomes red in colour – this is due to arteriolar dilatation (an attempt to remove built up metabolic waste)
To complete the examination

Thank patient
Wash hands
Summarise findings

 

Suggest further assessments & investigations:

CONTENT REVIEWED BY

Mr Craig NesbittSpR in Vascular Surgery

Mr Sandip NandhraSpR in Vascular Surgery

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