Peripheral Vascular Disease : Examination

                                                                PVD: Examination

GPE

·         Decubitus: affected legs hanging below the level of the bed

·         Pulse

·         Arcus senilis (not diagnostic of vascular disease but worth noting)

·         Xanthelesmata and xanthomata- cholesterol deposits around the eye and in the subcutaneous tissues indicative of hypercholesterolaemia (Norman Browse)

Local Examination

[A] Inspection

1.       attitude of limb

2.       any deformity—loss of toes or any other deformity

3.       Muscle wasting in thigh, calf or foot

4.       Condition of veins

§  any discoloration along the veins

§  any guttering along veins (ischemic limb)

5.       Signs of peripheral ischemia

·         Condition of skin

§  Thin shiny skin

§  Loss of subcutaneous fat

§  Loss of hair over toes, dorsum of foot

·         Changes in nail

§  Brittle

§  Transverse ridges

·         Gangrene

§  Site and extent of gangrene

§  Type (dry or moist)

§  Color of the gangrenous area

§  Line of demarcation

6.       Limb above the gangrenous area—whether pale, congested or edematous

[B] Palpation

1.       Skin temperature (compare with the normal)

2.       Gangrene

·         Site

·         Sensation

·         Tenderness

·         any local crepitus

·         Limb adjacent to gangrenous area

3.       Tenderness

4.       Pitting edema.

5.       Assessment of circulatory insufficiency

·         Test for capillary refilling—press the nail bed/or the pulpà releaseà note rapidity of capillary refilling

·         Venous refilling (Harvey's sign)— empty a segment of vein with two fingers àdistal fingers released      àlook for the timing of venous refilling

6.       Buerger’s test (for assessment of vascular angle)

·         Pallor on elevation of the limb to different angles( not very helpful in dark skinned individual)

·         Raise legs gradually àkeep at 30° angle to the bed for 2 minutes àlook for pallor àIf no pallor, raise limb to 45°/60°/90° àlook for pallor

·         Angle at which  pallor appears (Buerger’s angle of circulatory insufficiency)

7.       Crossed leg test (Fuchsig’s test)

·         Indirect test for assessment of presence of popliteal pulse

·         Patient sits on a chair with the legs crossedà let one knee rest on the other àdivert attentionàlook for oscillatory movement of upper legàif oscillatory movement is seen àpopliteal pulse is present

8.       Movements of joints adjacent to gangrenous area

9.       Examination for nerve lesion in lower limbs

·         Motor system of lower limbs:

§  Tone

§  Power of ankle dorsiflexor and plantar flexor

§  Power of knee flexor and extensor

§  Power of hip flexor/extensor/abductor/adductors

·         Sensory system in lower limbs

§  Crude touch and fine touch

§  Pain sensation tested by pin prick

§  Temperature sensation

·         Reflexes:

§  Ankle jerk/Knee jerk

§  Plantar response

10.   Examination of regional lymph nodes

11.   Palpation of peripheral pulses

(++ normal; + palpable but feeble; − not palpable)

·         Dorsalis pedis  (dorsum of the foot lateral to the tendonof extensor hallucis longus at the proximal intermetatarsus space)

·         Anterior tibial (in front of the ankle midway between the two malleoli and just lateral to the extensor hallucis longus tendon)

·         Posterior tibial

·         Popliteal (against the tibia in between the medial and lateral condyles of tibia)

·         Femoral(below the inguinal ligament at the level of the deep inguinal ring which is midway between the anterior superior iliac spine and the symphysis pubis)

·         Radial /Ulnar/ Brachial

·         Axillary/ Subclavian/ Carotid

·         Superficial temporal

12.   Condition of arterial wall

·         any tenderness along the vessel

13.   Auscultation along major arteries

3. Systemic examination

Remember (Norman Browse)

■ When a popliteal pulse is very easy to feel, the artery may be aneurysmal

■ The popliteal pulse should be palpable if the foot pulses are easy to feel and there is no adductor canal or femoral artery bruits.