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

Check out the peripheral vascular examination mark scheme here.

Check out our Varicose Vein Examination OSCE guide here.

 


Introduction

Wash your hands

Introduce yourself

Confirm the patient’s details (name and date of birth)

Explain the examination

Gain consent

Ask if the patient currently has any pain


General inspection

Note if the patient appears comfortable at rest

Look around the bedside for treatments or adjuncts (e.g. mobility aids, dressings, limb prosthesis)

Note any obvious scars (may provide clues as to previous surgical procedures)

Look for evidence of cyanosis or pallor of the limbs 

  • General inspection
    General inspection

Upper body

Inspection

Inspect for relevant clinical signs in the upper limbs:

  • Skin colour (e.g. cyanosis/pallor/erythema) – Raynaud’s
  • Tar staining – smoking is a risk factor for PVD
  • Tendon xanthomas – associated with hypercholesterolemia
  • Gangrene (necrosis secondary to inadequate limb perfusion)
  • Inspect upper limbs
    Inspect upper limbs

Palpation

Temperature

  • Compare the temperature of the upper limbs
  • You should ideally use the back of the same hand to assess the temperature of the patient’s limbs
  • A cold and pale limb may indicate poor arterial supply

 

Capillary refill time (CRT)

  • Prior to assessing CRT, ensure the patient has no pain in their fingers before pressing
  • Assess peripheral capillary refill time
  • An individual with normal peripheral perfusion should have a CRT less than 2 seconds

Pulses

Radial pulse

  • Assess rate and rhythm – palpate for at least 5 cardiac cycles
  • Assess for radio-radial delay can be associated subclavian artery stenosis (e.g. compression by a cervical rib) or aortic dissection

 

Brachial pulse

  • Assess the volume and character of the pulse

 

Carotid pulse

  • The carotid pulse can be located medial to the sternocleidomastoid and beside the trachea
  • Auscultate each carotid for a bruit (if a bruit is identified, DO NOT perform carotid palpation)
  • If no bruit is identified, palpate each carotid pulse in turn
  • NEVER palpate both carotid arteries simultaneously

 

Other things to consider

Blood pressure (BP)

  • Record BP in both arms – a significant difference can be associated with aortic aneurysm
  • You’ll usually not be required to check a patient’s BP in a peripheral vascular examination OSCE station, however you should acknowledge that you would ideally carry this out
  • Assess & compare upper limb temperature
    Assess & compare upper limb temperature

Abdomen

Ensure there is adequate exposure for abdominal examination:

  • If the patient is wearing shorts, the waistband should be positioned to at least the top of the pubic symphisis.

 

Aorta

The abdominal aorta can be located in the midline of the epigastrium:

  • Inspect the abdomen, looking for any obvious pulsation
  • Palpate either side of the aorta feeling for expansion (associated with aneurysm)
  • Auscultate for aortic bruits above the umbilicus (the relative location of the aortic bifurcation).

 

Renal bruits

  • Auscultate just above the umbilicus, slightly lateral to the midline (on each side)
  • A renal bruit would be suggestive of renal artery stenosis
  • Palpate abdominal aorta
    Palpate abdominal aorta

Lower limbs

Inspection

Inspect and compare the legs, looking for abnormalities:

  • Scars (e.g. bypass surgery/vein harvest sites)
  • Hair loss – associated with PVD
  • Discolouration (e.g. necrosis)
  • Ischaemic rubour – often mistaken for cellulitis
  • Pallor – suggests poor arterial supply
  • Missing limbs/toes (e.g. previous amputation)
  • Ulcers – look between toes and on the posterior aspect of the legs
  • Muscle wasting – can be associated with PVD
  • Ask the patient to wiggle their toes to perform a quick gross motor assessment

 

The typical features of arterial leg ulcers include the following:

  • Very painful
  • Deep punched out appearance
  • Located at the end of digits or over the lateral surface of the ankle
  • Inspect legs
    Inspect legs

Palpation

Temperature

  • Compare the temperature of the lower limbs
  • A cold and pale limb may indicate poor arterial supply

 

Capillary refill time (CRT)

  • Prior to assessing CRT, ensure the patient has no pain in their toes before pressing
  • Assess peripheral capillary refill time in the lower limbs
  • An individual with normal peripheral perfusion should have a CRT less than 2 seconds

 

Pulses

Work proximal to distal – this allows you to assess and 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 anterior superior iliac spine and the pubic symphysis 
  • Palpate to confirm its presence and assess the pulse volume
  • Assess for radio-femoral delaysuggestive of aortic coarctation
  • Auscultate to detect any bruitssuggestive of femoral or iliac stenosis

 

Popliteal pulse

  • Palpated in the inferior region of the popliteal fossa
  • With the patient prone, ask them to relax their legs
  • Place your thumbs on the tibial tuberosity
  • Passively flex the patient’s knee to 30º as you curl your fingers into the popliteal fossa. This should allow you to feel the pulse, as you compress the popliteal artery against the tibia.
  • This pulse is often difficult to palpate, so don’t pretend you can feel it, if you can’t. The popliteal artery is one of the deepest structures within the fossa, so the examiner will understand.

 

Posterior tibial pulse

  • Best palpated posterior to the medial malleolus of the tibia
  • Palpate to confirm its presence and compare pulse strength to the other foot

 

Dorsalis pedis pulse

  • Best palpated over the dorsum of the foot
  • The pulse can be located lateral to the extensor hallucis longus tendon, over the 2nd and 3rd cuneiform bones
  • Palpate to confirm its presence and compare pulse strength to the other foot
  • Leg temperature
    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)
  • Lower limb sensation
    Assess light touch sensation distally

Buerger’s test

Buerger’s test is typically performed if critical limb ischaemia is suspected.

1. Ensure the patient is positioned supine.

 

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

  • Observe for pallor, which occurs secondary to drainage of the superficial veins
  • If a limb develops pallor, note at what angle this occurs e.g. 20º (this is known as Buerger’s angle)
  • A healthy leg’s 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 the patient to place their legs over the side of the bed:

  • Observe for a reactive hyperaemia
  • A reactive hyperaemia involves the leg first returning to its normal pink colour and then becoming red in colour.
  • This colour change occurs as a result of arteriolar dilatation, which is a response to increased anaerobic metabolic waste build up in the lower limbs.

To complete the examination

Thank the patient

Wash your hands

Summarise your findings

 

Suggest further assessments and investigations:


REVIEWED BY

Mr Craig Nesbitt (MD, FRCS, MBChB Hons)

Consultant in Vascular Surgery

Mr Sandip Nandhra

SpR in Vascular Surgery


 

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