Peripheral Vascular Exam (PVD)

Peripheral Vascular Exam (PVD)

NOTE: Only the lower limb exam is required in ASCM1. The upper and lower limb exam is required in ASCM2

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should be supine on a flat bed
  • Drape the patient so the legs are exposed to the ASIS. Ensure the groin remains draped. Also expose the patients arms to at least the antecubital fossa

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Inspection

Inspection of the peripheral vascular system should include a general inspection, followed by a more specific inspection of the peripheral vascular system. Be sure to inspect bilaterally for symmetry, and include the posterior aspects, as well as the buttock and groin.

  •  General Appearance
    • Does the patient look sick? Are they in any obvious distress?
  • SEADS
    • Examine the upper and lower extremities for the following:
      • Swelling - This includes any edema
      • Erythema
      • Atrophy/Hypertrophy
      • Deformities - Includes bony abnormalities, masses, or protrusions
      • Skin Changes - Discolorations, thickening, hair loss, shiny skin
  • Ulcers (Arterial or Venous)
    • Arterial
      • Typically found on finger tips, betweel the toes and on the heel
      • Are painful, develop acutely, and have discrete borders
    • Venous
      • Typically found above or over the medial malleolus
      • Are painless, develop slowly, and have poorly defined borders
  • Varicose Veins
    • Engorged superficial veins
  • Signs of Central or Peripheral Cyanosis
    • Central Cyanosis - Bluish mucous membranes
    • Peripheral Cyanosis - Cool/bluish extremities

Palpation

Palpation of the periphal vascular system includes palpating for signs of arterial/venous insufficiency, followed by palpation of the peripheral pulses

  • Temperature
    • Run your hands down the extremities to feel for the temperature of the skin
      • Cool Extremities - Possible arterial insufficiency
      • Warm Extremities - Possible venous insufficiency
  • Edema
    • There are two types of edema
      • Pitting - Venous cause
      • Non-pitting - Lymphatic cause
    • Apply pressure with your thumb over the patient's tibia for 3-5 seconds. If pitting edema is present, an impression will remain
    • Pitting edema can also be assesed over the dorsum of the foot, or behind the medial malleolus
    • Grading of edema - INSERT HERE
  • Capillary Refill
    • Apply pressure to the nail bed of the patient's big toe or thumb
    • Upon release, observe for the return of color to the nail bed
      • Normal - Return of color within 3-4 seconds
      • Prolonged pallor may indicate arterial insufficiency
  • Tenderness
    • As you palpate the extremities, note any evidence of pain in the patient's face
    • Ask the patient to inform you if they feel any pain as you palpate
  • Pulses
    • When palpating the pulses, describe their rate, rhythm and amplitude. Amplitude is graded as follows:
      • 0: Absent
      • 1: Diminished
      • 2: Normal
      • 3: Increased or Bounding
      • 4: Aneurysmal
    • Carotid Pulse
      • Auscultation should be done before palpation. If a bruit is heard on auscultation, do not palpate the carotid pulse
      • Palpate between the anterior border of the sternocleidomastoid muscle, above the hyoid bone, and lateral to the thyroid cartilage
      • Palpate one carotid artery at a time, and palpate gently to avoid baroreceptor activation
    • Brachial
      • Palpate in the antecubital fossa, medial to the biceps tendon
    • Radial
      • Palpate just lateral to the flexor tendons of the wrist
    • Abdominal Aorta
      • Using both hands, apply pressure to the abdomen a few centimeters above the umbilicus.
      • Feel for an expanding, pulsatile mass
      • Attempt to estimate the width of the aorta

 Figure 1: Palpating for an Abdominal Aortic Aneurysm

Figure 1: Palpating for an Abdominal Aortic Aneurysm

    • Femoral
      • Palpate just inferior to the midpoint of the inguinal ligament (runs from the ASIS to the pubic symphysis)
    • Popliteal
      • Flex the patient's knee to ~90o
      • Using both hands, palpate firmly in the popliteal fossa
      • Substantial pressure may be required, as the popliteal artery is a deep structure
    • Posterior Tibial
      • Palpate posterior and slightly inferior to the medial malleolus
    • Dorsalis Pedis
      • Palpate lateral to the extensor hallucis longus tendon (identify this tendon by asking the patient to lift their big toe)

Auscultation

Using the diaphragm, auscultate for bruits over the following areas:

  • Carotid Arteries
    • Auscultate before palpating the carotid arteries
  • Abdominal Aorta
    • Auscultate a few centimeters above the umbilicus
  • Renal Arteries
    • Auscultate 5 cm above, and 3-5 cm to either side of midline
  • Femoral Arteries
    • Auscultate inferior to the midpoint of the inguinal ligament
  • Popliteal Arteries
    • Auscultate in the popliteal fossa

Special Tests

There are three special tests for the peripheral vascular system:

  • Pallor on Elevation
    • With the patient supine, elevate the patient's leg for 15-30 seconds by holding it at the ankle. 
    • Observe the color of the patient's leg
      • Normal - Mild pallor
      • Abnormal - Marked pallor. May indicate arterial insufficiency
    • Repeat the test with the other leg
  • Rubor on Dependency
    • Upon completion of pallor on elevation, lower the patient's leg and ask them to sit up and swing their legs out over the side of the bed. 
    • Observe the color of the patient's leg
      • Normal - Normal color returns within 10 seconds
      • Abnormal - Marked rubor (redness) in response to tissue hypoxia. This suggests severe arterial insufficiency
    • Repeat the test with the other leg
  • Allen Test
    • This test assess for arterial sufficiency in the radial and ulnar arteries
    • Ask the patient to make a tight fist
    • Use one of your hands to occlude the radial artery, and the other hand to occlude the ulnar artery
    • Ask the patient to open their hand. At this point their palm should be pale
    • Test for Radial Insufficiency:
      • Release the pressure from the radial artery while maintaining pressure over the ulnar artery
      • Observe for the return of color to the palm
        • Normal - Color returns within seconds
        • Abnormal - Color returns slowly, suggesting radial artery insufficiency
    • Test for Ulnar Insufficiency:
      • Release the pressure from the ulnar artery while maintaining pressure over the radial artery
      • Observe for the return of color to the palm
        • Normal - Color returns within seconds
        • Abnormal - Color returns slowly, suggesting ulnar artery insufficiency