I examined this patient's peripheral vascular system. On inspection from the end of the bed, the patient appeared comfortable at rest with no signs of vascular disease. Both limbs were pink and well perfused with normal capillary refill times. All pulses were present and equal bilaterally. Buerger's test was negative. To complete my examination, I would assess the cardiovascular system and test the relevant muscles and nerves of the affected limb, and perform duplex scans and ankle-brachial pressure indexes.

1. Peripheral
Vascular
Examination
By
Doctor Aram Baram MD,MRCSEd
1

3. Introduction
▪Smile, look patient in the eye, shake
hands, say your name and explain (in
non technical terms) what you are about
to do!
▪Obtain adequate exposure
–clothes removed above the waist (bra may
be left on)
▪Position patient correctly
–patient lying supine with upper body at ~ 45
degrees
3

4. General Inspection (cont.)
From the end of the bed take note of:
▪Any special aids, devices, drugs or
instructions around the bedside
▪Look at sputum mug contents
–amount & consistency
–mucoid, mucopurulent, purulent, blood-
stained
▪Check temperature chart
–febrile above 380
4

5. General Inspection (cont.)
▪First ask yourself a very
important Q … how sick does
the patient look?
▪Assess rate & depth of
respiration, breathing pattern at
rest
5

6. Vascular System Components
▪ Arteries
▪ Veins
– Deep veins of the legs carry 90% of venous
return from the lower extremities
– Superficial include great saphenous , small
saphenous and communicating veins
▪ Lymphatics and lymph nodes
– Only cervical, supraclavicular, axillary, arm and
leg nodes palpable
6

7. Peripheral Vascular Exam
▪ Upper limbs
– Size, symmetry, skin color, temp., edema
– Capillary refilling
– Subclavian, Axillary, Brachial, Ulnar and Radial
pulses
– Allen‟s test (radial and ulnar patency), venous
filling
▪ Legs
– Size, symmetry, skin color, temperature
– Femoral pulse, bruit and inguinal lymph nodes
– Popliteal, DPA and PTA pulses,
– Peripheral edema, ulcers/lesions 7

8. Introduction
▪ Introduce yourself
▪ Ask Permission to examine
▪ Expose the patient lower limbs
and upper limbs
▪ Ask the patient if they have any
pain
8

9. Stand at the end of the bed
STOP
Look for a few seconds
Show you are looking around
the bed
Oxygen
Inhalers
Catheters
Drains
Fluids
Dressings
Position
Comfortable?
9

10. LOOK…
▪ Stand at the end of the bed
• Colour of the Limbs (pale/blue/black)
• Hair Loss
• Ulcers
• Scars
• Muscle Wasting
10

11. LOOK...
▪ Move Closer (pressure areas)
• Lateral side of the foot
• Head of first metatarsal
• Heel
• Both Malleoli
• Tips of the Toes
▪ Look in between each of the toes
11

12. FEEL…
▪Run the back of your
hand down both
limbs
▪Compare both sides
▪Warm or cold?
▪Point of change?
▪Capillary Refill time
▪Pulses
12

13. PULSES...
▪ Upper limb
 Subclavain, Carotid, Brachial,
Radial, Ulnar, Allen‟s test, Cappillary
re-filling
▪ Lower Limb
– Aorta
– Femoral (mid inguinal point)
– Popliteal 3 methodes feel with 8 fingertips!!
– Posterior tibial
– Dorsalis Pedis
– Anterior tibial
13

14. Pulse Points
14

15. LISTEN...
▪Bruits at the
Aorta, Iliac and
Femoral arteries
▪Subclavian and
Carotid Arteries
15

16. There are several systems for grading the
amplitude of the arterial pulses.
▪4+ Bounding
▪3+ Increased
▪2+ Brisk, expected
▪1+ Diminished, weaker than
expected
▪0 Absent, unable to palpate
16

17. Radial pulse…
▪ Palpate the radial pulse with
the pads of your fingers on
the flexor surface of the wrist
laterally.
▪ Patient‟s wrist better to be in
neutral position, may help
you feel this pulse.
▪ Compare the pulses in both
arms
17

18. Brachial pulse…
Flex the patient‟s elbow
slightly, and with the thumb of
your opposite hand palpate the
artery just medial to the biceps
tendon at the antecubital
crease.
The brachial artery can also be
felt higher in the arm in the
groove between the biceps and
triceps muscles.
18

19. Subclavian artery…
▪Palpable
less
frequently
▪Audible
often
19

20. Carotid Arteries…
At the level of thyroid
cartilge
Opposite to the mid
third of the
sternoclidomastoide
It may be visible just
medial to the
sternomastoid muscles.
20

21. Abdominal Aorta…
Is an upper abdominal,
retroperitoneal structure which is
best palpated by applying firm
pressure with the flattened fingers
of both hands to indent the
epigastrium toward the vertebral
column.
In extremely obese individuals or
in those with massive abdominal
musculature, it may be impossible
to detect aortic pulsation.

Auscultation should be performed
over the aorta and along both iliac
vessels into the lower abdominal
quadrants.
21

22. Femoral Pulse…
▪ The common femoral artery emerges
into the upper thigh from beneath the
inguinal ligament , 1-2 inches below
the mid point symphysis pubis to the
anterior superior iliac spine.
▪ It is best palpated with the examiner
standing on the ipsilateral side of the
patient and the fingertips of the
examining hand pressed firmly into
the groin.
▪ Auscultation should be performed in
this area, as well.
22

23. Popliteal Artery…
23

24. Popliteal Artery…
It may be difficult or impossible to
palpate in obese or very muscular
individuals.
Generally this pulse is felt most
conveniently with the patient in the
supine position and the examiner's
hands encircling and supporting the
knee from each side.
The pulse is detected by pressing
deeply into the popliteal space with the
supporting fingertips.
Since complete relaxation of the
muscles is essential to this
examination, the patient should be
instructed to let the leg "go limp" and to
allow the examiner to provide all the
support needed. 24

25. Seconded Method
25

26. Third method…
26

27. The posterior tibial pulse…
The posterior tibial artery lies just
posterior to the medial malleolus.
It can be felt most readily by
curling the fingers of the examining
hand anteriorly around the ankle,
indenting the soft tissues in the
space between the medial
malleolus and the Achilles tendon,
above the calcaneus.
The thumb is applied to the
opposite side of the ankle in a
grasping fashion to provide
stability.
Again, obesity or edema may
prevent successful detection of the
pulse at the location.
27

28. The Dorsalis Pedis Artery
Is examined with the patient in the
recumbent position and the ankle
relaxed.
The examiner stands at the foot of
the examining table and places the
fingertips transversely across the
dorsum of the forefoot near the ankle.
The artery usually lies near the
center of the long axis of the foot,
lateral to the extensor hallucis tendon
but it may be aberrant in location and
often requires some searching.
This pulse is congenitally absent in
approximately 10% of individuals.
28

29. Bruits…
After palpating the artery,
auscultation for a bruit should be
performed.
Bruits are detected by auscultation
over the large and medium-sized
arteries (e.g., carotid, subclavain,
brachial, abdominal aorta, femoral)
with the diaphragm of the stethoscope
using light to moderate pressure.
Excessive pressure may produce,
intensify, or prevent a bruit from being
detected by indenting the vessel wall
or occluding blood flow in the artery.
One should listen over the artery after
palpation of the artery to avoid
overlooking a significant lesion.
29

30. Bruits…
▪ Occasionally, bruits are audible over the upper abdomen in
young, healthy individuals.
▪ These sounds apparently originate from tortuous vessels and
are of no clinical significance; if the subject has a normal
blood pressure and is free of abdominal symptoms, such
findings may be disregarded.
▪ Frequently the examiner will detect a "thrill" or palpable
vibratory sensation over a vessel in which a loud bruit is
audible.
▪ The thrill is indicative of marked turbulence in local blood
flow and suggests significant vascular pathology.
▪ If a thrill is noted during examination of the pulses, it should
be recorded in the appropriate space on the data base.
30

31. FURTHER TESTS...
▪ Elevate to 15 degrees ?venous guttering
▪ Elevate leg further. Note angle at which
turns pale (BUERGER‟S ANGLE)
▪ Ask patient to hang their leg over the edge
of the bed (BUERGER‟S TEST)
White  Pink  Flushed purple-red
(Reactive Hyperaemia)
31

32. THEN
▪ Cover the patient up & thank them
▪ Turn to the examiner and present your findings…..
32

33. Formulate Your Presentation
I examined this elderly gentleman‟s
peripheral vascular system.
On inspection from the end of the bed he
appeared comfortable at rest with no
peripheral signs of vascular disease.
Both limbs were pink and well perfused with
capillary refill time < 2secs.
All pulses were present and equal on both
sides. Buerger‟s test was negative.
33

34. TO COMPLETE MY
EXAMINATION…..
▪ I would like to examine the rest of the peripheral
vascular system including the cardiovascular
system
▪ Test the relevant muscles and nerves of the
affected limb
▪ Perform a duplex scan and ABPI‟s
34

35. Venous examination
▪ INSPECTION:
▪ General Appearance:
▪ Veins –Distribution / Size / Size of and visible sc veins
▪ Varicose Veins are by definition dilated and tortuous.
▪ Compare size of both legs esp at ankle level for evidence of
oedema.
▪ Venous Stars – minute veins radiating from a single feeding
vein.
▪ Skin – Inspect the skin of the whole leg but particularly the
lower medial third since venous dx affects this area first,
causing Pigmentation / Eczema and Ulceration.
▪ Signs of Chronic Venous Insufficiency – lipodermatosclerosis =
▪ Ulcers -
35

36. Palpation
Fascial Defects - Feel along course of
veins (Note tension in vein) and any tender
fascial defects (usually at 5, 10 and 15 cm
above medial malleolus)
Pitting Oedema
Sc Tissues - Thickening and tenderness
Vein - Press on vein from above noting
presence of retrograde flow
Cough impulses - over saphenofemoral
and saphenopopliteal junctions
36

37. Palpation...
TRENDELENBERG TEST:
Ask the patient to lie down & raise the leg
to empty the veins.
Place 2 fingers ove the spahenofemoral
junction.
Ask the patient to stand up. If the veins
remain empty while standing, the
saphenofemoral junction is incompetent.
Release pressure at the junction to see!
NB. “This test is unreliable, so I would
perform a Doppler Assessment as an
alternative”. 37

38. Palpation...
▪TOURNIQUET TESTS:
▪ Patient Supine with Leg elevated
▪ Sweep veins empty (Note how easily the veins empty - may
give signs of occlusion / compression). (if fail to empty this
suggests high pressure within them)
▪ First place a tourniquet around upper third of thigh to occlude
superficial veins
▪ Now, Patient Standing
▪ If veins above tourniquet distend - Saphenofemoral Junction
is incompetent
▪ If veins below tourniquet fill there must be a perforator below
level of tourniquet therefore once again elevate the leg and
repeat the procedure with the tourniquet at a lower position
on leg.
▪ (Note: Alternatively – one can use multiple tourniquets and
simply release them sequentially)
38

39. AUSCULTATION:
▪Venous Clusters - may
represent AV fistula
▪Thank the patient & turn
to the examiner to
present your findings
39

40. I examined……
I examined this ladies venous system of
her lower legs.
On general inspection there were
varicosities in the distribution of the long
saphenous vein of the right leg.
There was no evidence of haemosiderin
deposits or ulceration.
Trendelenburgs test revealed
incompetence at the saphenofemoral
junction
40

41. TO COMPLETE MY EXAMINATION
▪I would like to
▪Examine the abdomen
▪Perform a DRE
▪A pelvic examination/examine
the external genitalia
41

42. Thoracic cage - bony
landmarks
▪ Clavicle; A-C joint;
S-C joint
▪ Sternal angle;
QuickTime™ and a xiphisternum;
Video decompressor
are needed to see this picture. sternal notch
▪ Rib counting using
sternal angle as key
landmark
43

43. Thoracic Muscles
1. pectoralis minor
2. pectoralis major
3. deltoid
4. rectus abdominus
5. external oblique
(interdigitating with
serratus anterior)
44

44. Surface Projections
▪ midline
▪ mid-clavicular line
– midway between
sternoclavicular joint
& acromioclavicular
joint
▪ anterior axillary line
45

45. Surface Projections
▪ Anterior axillary line
– anterior fold of
pectoralis major
▪ Mid-axillary line
▪ Posterior axillary line
– posterior fold of
latissimus dorsi
46

46. Surface Projections
▪ midline
▪ medial scapular line
▪ paravertebral line
47

47. Respiratory System
▪ pleural reflections & extensions
▪ surface projections of lungs
▪ fissures & lobes
▪ bronchopulmonary segments
48

48. Lung markings - Anterior
▪ during quiet
respiration lungs at:
rib 6 (mid-clavicular line)
rib 8 (mid axillary line)
rib 10 (paravertebral line)
▪ pleural reflections 2
ribs below at ribs 8, 10
& 12
▪ horizontal fissure to
4th costal cartilage
▪ oblique fissure to 6th
costal cartilage
49

49. Lung markings - Posterior
▪ oblique fissure begins
posteriorly opposite 3rd
thoracic spinous
process
▪ oblique fissure divides
lungs into upper and
lower lobes
▪ note how high the lower
lobe of each lung
extends!
50

50. Lung Surface Projections -
Lateral
51

51. Bronchopulmonary
Segments
52

52. Left Lateral View
53

53. Routine CXR
▪ normal
▪ cardiac shadow
▪ bronchial tree
▪ lung & pleura
▪ ribs
– anterior
– posterior
54

54. the not so „routine‟ CXR ...
right upper lobe consolidation left pleural effusion
55

55. right haemopneumothorax
56

56. left pulmonary mass
57

57. pulmonary metastases
58

58. right tension pneumothorax
59

59. 60