In medicine

Medicine

Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

, the peripheral vascular examination is a series of maneuvers to elicit signs of peripheral vascular pathology

Pathology

Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....

. It is performed as part of a physical examination

Physical examination

Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...

, or when a patient presents with leg pain suggestive of a cardiovascular pathology

Pathology

Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....

.

The exam includes several parts:

• Position/Lighting/Draping
• Inspection
• Palpation
  Palpation
  Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...
  
  
• Auscultation
  Auscultation
  Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope...
  
  
• Special maneuvers

Position/Lighting/Draping

Position - patient should be lying in the supine position

Supine position

The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...

 and the bed or examination table should be flat. The patient's hands should remain at her sides with her head resting on a pillow.

Lighting - adjusted so that it is ideal.

Draping - the legs should be exposed, the private groin and thigh covered. Drapes are usually placed between the legs.

Inspection

On inspection the physician looks for signs of:

• trauma
  Physical trauma
  Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
  
  
• previous surgery (scar
  Scar
  Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
  
  s)
• muscle wasting/muscle asymmetry
• edema (swelling)
• erythema
  Erythema
  Erythema is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin. It occurs with any skin injury, infection, or inflammation...
  
   (redness)
• ulcers
  Venous ulcer
  Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs. They are the major cause of chronic wounds, occurring in 70% to 90% of chronic wound cases...
  
   - arterial ulcers tend to be on the borders / sides of the foot, neuropathic ulcers on the plantar surface of the foot, venous ulcers tend on be on the medial aspect of the leg superior to the medial malleolus.
• hair - hair is absent in peripheral vascular disease (PVD)
• shiny skin - seen in PVD
• Haemosiderin deposits
• Lipodermatosclerosis

Palpation

• Temperature
  Temperature
  Temperature is a physical property of matter that quantitatively expresses the common notions of hot and cold. Objects of low temperature are cold, while various degrees of higher temperatures are referred to as warm or hot...
  
   - cool suggest poor circulation, sides should be compared
• Pitting edema
  Edema
  Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
  
   - should be tested for in dependent locations - dorsum of foot, if present then on the shins. If the patient has been in bed for a longer period of time one should check the sacrum
  Sacrum
  In vertebrate anatomy the sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...
  
  .
• Capillary refill
  Capillary refill
  Capillary refill is the rate at which blood refills empty capillaries. It can be measured by holding a hand higher than heart-level , pressing the soft pad of a finger or toe until it turns white, and taking note of the time needed for the color to return once pressure is released. Normal refill...
  
   - should be less than 3 seconds.

Arterial pulses

• Dorsalis pedis artery
  Dorsalis pedis artery
  In human anatomy, the dorsalis pedis artery , is a blood vessel of the lower limb that carries oxygenated blood from the dorsal surface of the foot. It arises at the anterior aspect of the ankle joint and is a continuation of the anterior tibial artery...
  
   pulse
  Pulse
  In medicine, one's pulse represents the tactile arterial palpation of the heartbeat by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed against a bone, such as at the neck , at the wrist , behind the knee , on the inside of the elbow , and near the...
  
   - on dorsal surface of the foot, running lateral to the tendon of the first toe
• Posterior tibial artery
  Posterior tibial artery
  The posterior tibial artery of the lower limb carries blood to the posterior compartment of the leg and plantar surface of the foot, from the popliteal artery...
  
   pulse - posterior and inferior to the medial malleolus
• Popliteal artery
  Popliteal artery
  In human anatomy, the popliteal artery is defined as the extension of the "superficial" femoral artery after passing through the adductor canal and adductor hiatus above the knee...
  
   pulse - behind the knee
  Knee
  The knee joint joins the thigh with the leg and consists of two articulations: one between the fibula and tibia, and one between the femur and patella. It is the largest joint in the human body and is very complicated. The knee is a mobile trocho-ginglymus , which permits flexion and extension as...
  
  , typically done with both hands
• Femoral artery
  Femoral artery
  The femoral artery is a general term comprising a few large arteries in the thigh. They begin at the inguinal ligament and end just above the knee at adductor canal or Hunter's canal traversing the extent of the femur bone....
  
   pulse - in the femoral triangle / halfway between the ASIS and pubic symphysis

Special maneuvers

• Ankle-brachial pressure index (ABPI) assesses peripheral vascular disease. It may however be unreliable in patients with calcified arteries in the calf (often diabetic patients) or those with extensive oedema.

• Venous refill with dependency (should be less than 30 seconds) - the vein should bulge outward within 30 seconds of elevation for one minute.

• Buerger's Test (assessment of arterial sufficiency):
  With the patient supine, note the colour of the feet soles. They should be pink. Then elevate both legs to 45 degrees for more than 1 minute. Observe the soles. If there is marked pallor (whiteness), ischemia should be suspected. Next check for rubor of dependency. Sit the patient upright and observe the feet. In normal patients, the feet quickly turn pink. If, more slowly, they turn red like a cooked lobster
  Lobster
  Clawed lobsters comprise a family of large marine crustaceans. Highly prized as seafood, lobsters are economically important, and are often one of the most profitable commodities in coastal areas they populate.Though several groups of crustaceans are known as lobsters, the clawed lobsters are most...
  
  , suspect ischemia
  Ischemia
  In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
  
  .

• Brodie-Trendelenburg Test (assessment of valvular competence if varicose veins
  Varicose veins
  Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards . Leg muscles pump the veins to return blood to the heart, against the...
  
   are present):
  One leg at a time. With the patient supine, empty the superficial veins by 'milking' the leg in the distal to proximal direction. Now press with your thumb over the saphenofemoral junction (2 cm below and 2 cm lateral to the pubic tubercle
  Pubic tubercle
  The pubic tubercle is a prominent forward-projecting tubercle on the upper border of the medial portion of the superior ramus of the pubis...
  
  ) and ask the patient to stand while you maintain pressure. If the leg veins now refill rapidly, the incompentence is located below the saphenofemoral junction, and vice versa. This test can be repeated using pressure at any point along the leg until the incompetence has been mapped out.

External links

• http://jama.ama-assn.org/cgi/content/full/300/2/197 JAMA: Ankle Brachial Index
• http://circ.ahajournals.org/cgi/content/full/105/7/886 Circulation: Tools for Coronary Risk Assessment