Medically Fit For Exams
Medically Fit For Exams

Peripheral arterial examination (lower limb)

Wash hands

 

Introduction and consent

  • Explain that you will need them to remove their trousers

 

6 Ps of acutely ischaemic limb

Pulselessness

Pallor

Perishing cold

Pain – eg calf muscle tenderness, spasms/pain on squeezing or exercise

Paraesthesia – loss of sensory function

Paralysis – loss of motor function

 

 

 

 

 

 

 

 

 

 

 

 

General inspection

  • Should remove trousers if they will restrict the legs
  • Look at footwear
  • Look for walking aids
  • Look for medication

 

Hands

  • Tar stains
  • Capillary refill

 

Pulse and blood pressure

  • Take both radial pulses simultaneous – check for atrial fibrillation
  • Say that you would check their blood pressure on both sides

 

Face

  • Corneal arcus (white ring)
  • Xanthalasmata (cholesterol deposits around the eyes)
  • Say that you would perform fundoscopy

 

Inspection of legs

  • Lay patient on the bed and expose the legs
  • Inspect both legs, look between the toes, under the heels
  • Note scars, lesions, ulcers, skin breaks, pressure areas, dressings
  • Note the colour of the skin
  • Look for asymmetry of the muscles
  • Skin changes – hair loss, skin thickening, dry skin
  • Swelling, including Charcot joints
  • Nail changes
  • Varicose veins
  • Ulcers – venous or arterial
    • Venous – more common, 80% medial, 20% lateral, shallow, irregular shape, can be large, can be green and sloughy over a pink/granulating base
    • Arterial – less common, generally appear on pressure areas, small, regular shape, ‘punched out’ appearance, may have a sloughy or necrotic base

 

Palpate

  • Temperature – may be cooler if vascular supply is compromised
  • Capillary refill - <3 seconds after pressing nail bed for 5 secs
  • (Pitting) oedema
  • Sensation, can use neurotip, sharp vs blunt, tuning fork
  • Gently squeeze calf – will be tender in acute limb ischemia
  • Pulses – dorsalis pedis, posterior tibial, popliteal and femoral (in that order)
    • Can use a Doppler if struggling to find them
  • Auscultate for femoral bruits (if sufficiently undressed)
  • Palpate for AAA

 

Buerger’s test

  • Ask patient to lie flat
  • Raise the limb slowly, up to angle of 45 degrees, flex at hip joint
  • Note the angle at which the limb gets paler – this is the Buerger’s angle, the smaller the angle, the more severe the ischemia
  • If it has not paled by 45 degrees, hold here for 2 minutes. A normal limb should not get pale
  • Now ask the patient to sit up with their legs hanging off the bed
  • Normal legs will go pink as blood refills
  • Abnormal result – legs go dark dusky red – this is reactive hyperaemia
  • This can be painful, so warn the patient and be gentle

 

Further examination and investigation

  • State that you would go on to do a full cardiovascular exam
  • State that you would like to do an ABPI
  • State that you would like to do a doppler ultrasound
  • If abnormalities found, state that you would like to do angiography (CT or MRI)

 

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