Arterial vascular examination (upper and lower limb)
Upper and lower limb arterial examination and questions for medical student exams, finals, OSCEs and MRCP PACES
Intro (WIIPPPPE)
- Wash your hands
- Introduce yourself
- Identity of patient (confirm)
- Permission (consent and explain examination)
- Pain?
- Position at 45°
- Privacy
- Expose upper limbs and chest initially
General Inspection
- Surroundings
- Monitoring:
- Pulse oximeter
- ECG monitoring
- Monitoring:
- Treatments:
- Oxygen therapy (method of delivery and rate)
- GTN spray
- Insulin pen
- IV infusions
- Paraphernalia:
- Wheelchair or walking aids
- Food and drink
- Cigarettes/ nicotine patches/ gum
- Patient
- Well or unwell?
- Comfortable at rest or in pain?
- Body habitus: cachectic or obese?
- Smoker’s facies or smell of cigarettes?
- Colour: Peripheral cyanosis? Mottled?
- Signs of peripheral arterial disease (ulcers, gangrenous toes, amputations)
- Scars? (CABG, graft harvesting, groin scars from angiography)
Systemic examination
- Upper limbs
- Inspect
- Colour (peripheral cyanosis/ mottled discolouration)
- Cigarette tar staining (not nicotine!)
- Blood glucose testing on fingertips
- Tendon xanthomata (hyperlipidaemia)
- Scars (radial artery harvest for CABG, wrist scars from angiography/ interventional radiology)
- Subclavian artery aneurysm
- Palpate
- Temperature
- Gross sensation (distal to proximal)
- Capillary refill (at level of heart, both limbs, normal <2s)
- Radial pulse (rate, rhythm)
- Radio-radial delay
- Aortic dissection
- Aortic coarctation (delayed on left depending on level of coarctation)
- Subclavian artery stenosis
- Radio-femoral delay
- Aortic coarctation
- Brachial pulse [only necessary if you fail to feel a radial pulse]
- Ask for blood pressure in both arms. Unequal BPs suggest:
- Aortic dissection (BP reduced on left depending on level of dissection)
- Subclavian artery stenosis (BP reduced on side of stenosis)
- Aortic coarctation (BP reduced on left depending on level of coarctation)
- Carotid pulse
- Auscultate
- Carotid bruits
- Inspect
Peripheral vascular exam video
- Abdomen
- Inspect (at level of patient)
- Scars: midline laparotomy or T shaped scar (suggests emergency AAA repair)
- Pulsatile aorta
- Palpate
- Aorta (above umbilicus): Pulsatile AND expansile? Approximate diameter?
- The aorta should be pulsatile but should not be expansile.
- Auscultate
- Aortic bruit (above umbilicus)
- Renal bruits
- Aorta (above umbilicus): Pulsatile AND expansile? Approximate diameter?
- Inspect (at level of patient)
- Lower limbs
- Inspect
- Colour: peripheral cyanosis/ mottled discolouration
- Skin: shiny or hairless
- Scars
- Long saphenous vein harvesting for CABG
- Groin scars from angiography/ interventional radiology/ EVAR/ angioplasty/catheter-directed thrombolysis
- Ulcers
- Arterial ulcer sites: dorsum of foot, between toes, tips of toes
- Diabetic ulcer sites: pressure points (heel, metatarsal heads)
- Palpate
- Temperature
- Gross sensation (distal to proximal)
- Capillary refill
- Femoral pulses: mid-inguinal point, halfway between ASIS and pubic symphysis
- Radio-femoral delay (if not already done)
- Popliteal pulses
- 10% of patients with popliteal aneurysm have an AAA
- 30% of patients with AAA have a popliteal aneurysm
- Dorsalis pedis (lateral to tendon of extensor hallucis longus)
- Absent in 10% of normal people
- Posterior tibial pulses (2cm below and behind medial malleolus)
- Auscultate
- Femoral bruits
- Inspect
Closure
- Thank patient, ensure they’re comfortable and ask if they need any help in getting dressed
- Wash hands
- Turn to examiner, hands behind back, holding stethoscope, before saying: “To complete my examination, I would like to…”
- Further examinations:
- Perform a full cardiovascular examination
- Perform neurological and venous examination of the upper and lower limb
- Special test: perform Buerger’s test if indicated
- Bedside investigations:
- Ankle-Brachial Pressure Index (ABPI)
- Measure claudication distance and total walking distance
- 12-lead ECG
- Capillary blood glucose
- Fundoscopy (for hypertensive and diabetic retinopathy)
- Further investigations:
- Bloods (FBC, U&Es, lipids, ESR/CRP, glucose and HbA1c, thrombophilia screen if indicated)
- Arterial duplex
- Angiography
- Further examinations:
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Upper and lower limb arterial examination exam questions for medical students, finals, OSCEs and MRCP PACES