Physical Diagnostics –
Vascular Examination
DR.LIKA KHORBALADZE
Vascular system:
The vascular system is made up of the vessels that carry blood and
lymph fluid through the body. It's also called the circulatory
system. The arteries and veins carry blood all over the body. They
send oxygen and nutrients to the body tissues. And they take away
tissue waste. The lymph vessels carry lymphatic fluid. This is a clear,
colorless fluid made of water and blood cells. The lymphatic system
is part of the immune system that helps rid the body of toxins and
waste. It does this by filtering and draining lymph away from each
region of the body.
Vascular system:
The vessels of the blood circulatory system are:
Arteries. These are blood vessels that carry oxygenated blood away
from the heart to the body.
Veins. These are blood vessels that carry blood from the body back
into the heart.
Capillaries. These are tiny blood vessels between arteries and veins
that distribute oxygen-rich blood to the body.
Lymphatic vessels: vessels that carry Lymph.
Examination: History Taking
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Age & Sex
Limbs affected
Bilateral or Unilateral
Mode of onset
Pain:
Intermittent Claudication - is muscle pain that happens when
person is active and stops when one rest. It's usually a symptom
of blood flow problems like peripheral artery disease.
Rest pain
Examination: History Taking
• Effect of heat, cold, emotional stress.
• History of Superficial Phlebitis
• Past Medical History:
Embolism
Myocardial Infarction
Diabetes Mellitus
Examination: History Taking
• Trauma
Accidents - fractures, Injury to the arms or legs; Changes in the muscles or
ligaments
Stabs - straight trauma of vessels
Gunshot – primary and secondary injury of vessels
Examination: History Taking
• Personal History:
– Smoking.
– Fatty Diet
– Poor Lifestyle – no exercise
• Impotence
• Occupational history – sedentary lifestyle
General Examination: General inspection:
How does patient look?
➢ pain in the thigh, calf or buttocks while
or exercising.
walking
➢Pale or bluish skin
➢Lack of leg hair or toenail growth
➢Sores on toes, feet, or legs that heal slowly or
not at all
➢Decreased skin temperature, or thin, brittle,
shiny skin on the legs and feet
➢Weak pulses in the legs and the feet
➢Gangrene
➢Impotence
➢ Wounds that won’t heal over pressure points,
such as heels or ankles
➢Numbness, weakness, or heaviness in muscles
➢Burning or aching pain at rest, commonly in the
toes and at night while lying flat
➢Restricted mobility
➢Thickened, opaque toenails
➢Varicose veins
Physical Examination
• Inspection
• Palpation
• Auscultation
• Comparison
• Special tests
Inspection:
Inspect and compare the upper limbs:
Peripheral cyanosis: bluish discolouration of the skin associated with low SpO2 in the
affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).
Peripheral pallor: a pale colour of the skin that can suggest poor perfusion (e.g. PVD).
Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g.
PVD, coronary artery disease, hypertension).
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm,
tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia
(typically familial hypercholesterolaemia), another important risk factor for
cardiovascular disease.
Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances
include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.
Inspection:
Inspect and compare the lower limbs:
colour (e.g. red, black) and breakdown of the associated
tissue.
• Peripheral cyanosis: bluish discolouration of the skin
associated with low SpO2 in the affected tissues (e.g. may • Missing limbs, toes, fingers: due to amputation secondary
to critical ischaemia.
be present in the peripheries in PVD due to poor
perfusion).
• Scars: may indicate previous surgical procedures (e.g.
bypass surgery) or healed ulcers.
• Peripheral pallor: a pale colour of the skin that can
suggest poor perfusion.
• Hair loss: associated with PVD due to chronic impairment
of tissue perfusion.
• Ischaemic rubour: a dusky-red discolouration of the leg
that typically develops when the limb is dependent.
Ischaemic rubour occurs due to the loss of capillary tone • Muscle wasting: associated with chronic peripheral
vascular disease.
associated with PVD.
• Xanthomata: raised yellow cholesterol-rich deposits that
• Venous ulcers: typically large and shallow ulcers with
irregular borders that are only mildly painful. These ulcers may be present over the knee or ankle. Xanthomata are
associated with hyperlipidaemia (typically familial
most commonly develop over the medial aspect of the
hypercholesterolaemia), another important risk factor for
ankle.
cardiovascular disease.
• Arterial ulcers: typically small, well-defined, deep ulcers
• Paralysis: critical limb ischaemia can cause weakness and
that are very painful. These ulcers most commonly
paralysis of a limb. To perform a quick gross motor
develop in the most peripheral regions of a limb (e.g. the
assessment, ask the patient to wiggle their toes.
ends of digits).
• Gangrene: tissue necrosis secondary to inadequate
perfusion. Typical appearances include a change in skin
Certain physical appearances should always
prompt an awareness of cardiac abnormalities
Genetic disorder
Associated cardiac manifestation
Marfan's syndrome
Aortic regurgitation (aortic dissection)
Down's syndrome
ASD, VSD
Turner's syndrome
Coarctation of the aorta
Spondyloarthritides, eg, ankylosing spondylitis
Aortic regurgitation
ASD: atrial septal defect; VSD: ventricular septal defect
Facial signs associated with cardiac conditions
Facial sign
Description
Possible cardiac association
Malar flush
Redness around the cheeks
Mitral stenosis
Xanthomata
Yellowish deposits of lipid around
the eyes, palms, or tendons
Hyperlipidemia
Corneal arcus
A ring around the cornea
Age, hyperlipidemia
Proptosis
Forward projection or
displacement of the eyeball;
occurs in patients with Graves'
disease
Atrial fibrillation
Palpation:
Temperature
Place the dorsal aspect of your hand onto the patient’s upper limbs to assess temperature:
•In healthy individuals, the upper limbs should be symmetrically warm, suggesting adequate perfusion.
•A cool and pale limb is indicative of poor arterial perfusion.
Capillary refill time (CRT)
Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:
•Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
•In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than
two seconds.
•A CRT that is greater than two seconds suggests poor peripheral perfusion.
•Prior to assessing CRT, check that the patient does not currently have pain in their fingers.
Palpation: Taking the pulse - Taking the pulse is one
of the simplest, oldest, and yet most informative of all clinical
tests.
Peripheral signs associated with infective endocarditis
Peripheral sign
Description
Cardiac association
Clubbing
Broadening or thickening of the
Infective endocarditis, cyanotic
tips of the fingers (and toes) with congenital heart disease
increased lengthwise curvature of
the nail and a decrease in the
angle normally seen between the
cuticle and the fingernail
Splinter hemorrhages
Streak hemorrhages in nailbeds
Infective endocarditis
Janeway lesions
Macules on the back of the hand
Infective endocarditis
Osler's nodes
Tender nodules in fingertips
Infective endocarditis
Palpation: Taking the pulse - Abnormal pulses
Type of pulse
Pulse characteristics
Most likely cause
Regularly irregular
–
2nd-degree heart block, ventricular
bigeminy
Irregularly irregular
–
Atrial fibrillation, frequent ventricular
ectopics
Slow rising
Low gradient upstroke
Aortic stenosis
Waterhammer, collapsing
Steep up and down stroke (lift arm so that wrist is
above heart height)
Aortic regurgitation, patent ductus
arteriosus
Bisferiens
A double-peaked pulse – the second peak can be
smaller, larger, or the same size as the first
Aortic regurgitation, hypertrophic
cardiomyopathy
Pulsus paradoxus
An exaggerated fall in pulse volume on inspiration
(>10 mm Hg on sphygmomanometry)
Cardiac tamponade, acute asthma
Bounding
Large volume
Anemia, hepatic failure, type 2 respiratory
failure (high CO2)
Pulsus alternans
Alternating large and small volume pulses
Bigeminy
Peripheral pulses:
Radial pulse
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of
your index and middle fingers aligned longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm, palpating for at least 5 cardiac
cycles.
Brachial pulse
Palpate the brachial pulse in each arm, assessing volume and character:
•Support the patient’s right forearm with your left hand.
•Position the patient so that their upper arm is abducted, their elbow is partially flexed and their
forearm is externally rotated.
•With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial
epicondyle of the humerus.
•Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial
artery.
Peripheral pulses
Peripheral pulses should also be documented, as peripheral vascular disease is
an important predictor of coronary artery disease:
•femoral – feel at the midinguinal point (midway between the symphysis pubis
and the anterior superior iliac spine, just inferior to the inguinal ligament)
•popliteal – feel deep in the center of the popliteal fossa with the patient lying
on their back with their knees bent
•posterior tibial – feel behind the medial malleolus
•dorsalis pedis – feel over the second metatarsal bone just lateral to the extensor
hallucis tendon
Blood pressure (BP)
Measure the patient’s blood pressure in both arms
Wide pulse pressure (more than 100 mmHg of difference between
systolic and diastolic blood pressure) can be associated
with aortic regurgitation and aortic dissection.
A more than 20 mmHg difference in BP between arms is abnormal
and is associated with aortic dissection.
Palpate the carotid pulse
If no bruits were identified, proceed to carotid pulse palpation:
1. Ensure the patient is positioned safely on the bed, as there is a
risk of inducing reflex bradycardia when palpating the carotid artery
(potentially causing a syncopal episode).
2. Gently place your fingers between the larynx and the anterior
border of the sternocleidomastoid muscle to locate the carotid
pulse.
3. Assess the character (e.g. slow-rising, thready) and volume of the
pulse.
Sensation
Slowly progressive peripheral neuropathy is common in patients with significant
peripheral vascular disease. This results in a glove and stocking distribution of
sensory loss. Acute critical limb ischaemia causes rapid onset parathesia in the
affected limb.
Gross peripheral sensation assessment
Perform a gross assessment of peripheral sensation:
1. Ask the patient to close their eyes whilst you touch their sternum with a wisp of cotton wool
to provide an example of light touch sensation.
2. Ask the patient to say “yes” when they feel the sensation.
3. Using the wisp of cotton wool, begin to assess light touch sensation moving distal to proximal,
comparing each side as you go by asking the patient if it feels the same:
If sensation is intact distally, no further assessment is required.
If there is a sensory deficit, continue to move proximally until the patient is able to feel the
cotton wool and note the level at which this occurs.
Auscultation:
Auscultate the carotid artery
Prior to palpating the carotid artery, you need to auscultate the vessel to
rule out the presence of a bruit. The presence of a bruit suggests
underlying carotid stenosis, making palpation of the vessel potentially
dangerous due to the risk of dislodging a carotid plaque and causing an
ischaemic stroke.
Place the diaphragm of your stethoscope between the larynx and
the anterior border of the sternocleidomastoid muscle over the carotid
pulse and ask the patient to take a deep breath and then hold it whilst
you listen.
Be aware that at this point in the examination, the presence of a ‘carotid
bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).
Auscultation
Auscultate the aorta and renal arteries
Auscultate over the aorta and renal arteries to identify vascular
bruits suggestive of turbulent blood flow:
Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit
here may be associated with an abdominal aortic aneurysm.
Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly
lateral to the midline on each side. A bruit in this location may be
associated with renal artery stenosis.
Special Tests: Modified Allen’s test
To perform a modified Allen’s test:
1. Ask the patient to clench their fist.
2. Apply pressure over the radial and ulnar artery to occlude both vessels.
3. Ask the patient to open their hand, which should now appear blanched. If the hand does not
appear it suggests you are not completely occluding the arteries with your fingers.
4. Remove the pressure from the ulnar artery whilst maintaining pressure over the radial artery.
5. If there is adequate blood supply from the ulnar artery, the normal colour should return to
the entire hand within 5-15 seconds. If the return of colour takes longer, this suggests poor
collateral circulation Do not perform arterial blood gas sampling on a hand that does not appear
to have an adequate collateral blood supply.
It should be noted that there is no evidence performing this test reduces the rate of ischaemic
complications of arterial sampling.
Special Tests: Adson's Test
Purpose of Test: Test for the presence of Thoracic Outlet syndrome, specifically compression between
the Anterior and Middle Scalene Muscles.
Test Position: Standing.
Performing the Test: Palpate the radial pulse on the affected side with the elbow fully extended. Have
the patient rotate their head to the side being tested and extend the neck. Next, abduct, extend, and
laterally rotate the shoulder. From this position, have the patient take a deep breath and hold. Assess
the pulse response. A positive test is a decrease in pulse vigor from the starting position to the final
position.
Importance of Test: Patients with Vascular types of thoracic outlet syndrome often describe their pain
as a fullness, heaviness, clumsiness, or weakness in their arm. The patient may also have subjective
complaints of swelling, either permanent or intermittent. When performing Adson's Test, the
examiner is placing the patient in a position that compresses the subclavian artery between the
anterior and middle scalene, thus resulting in a decrease in pulse strength. When performing Adson's
Test, it is important to test the contralateral side as well to understand the patient's normal radial
pulse.
Special Tests: Buerger’s test
Buerger’s test is used to assess the adequacy of the arterial supply to the leg.
To perform Buerger’s test:
1. With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to
45º for 1-2 minutes.
2. Observe the colour of the limbs:
The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity,
resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known
as Buerger’s angle.
In a healthy individual, the entire leg should remain pink, even at an angle of 90º.
A Buerger’s angle of less than 20º indicates severe limb ischaemia.
3. Sit the patient up and ask them to hang their legs down over the side of the bed:
Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb.
The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue.
Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteiolar dilatation (driven by
anaerobic metabolic waste products).
Ankle-brachial Pressure Index (ABPI)
Measurement
Measure the brachial pressure
1. With the patient lying on the examination couch, place the sphygmomanometer cuff over the
left arm proximal to the brachial artery and position the Doppler probe on the brachial artery at
a 45° angle (medial to the biceps tendon in the antecubital fossa).
2. Inflate the cuff 20-30 mmHg above the pressure at which the Doppler pulse is no longer
audible and then deflate the cuff slowly, noting the pressure at which you first detect a pulse
from the Doppler. This represents the systolic pressure in the vessel being assessed.
3. Now repeat steps 1 and 2 on the right brachial artery to assess systolic pressure.
4. Record the higher of the two systolic readings for use when calculating ABPI.
Ankle-brachial Pressure Index (ABPI)
Measurement
Measure the ankle pressure
1. Place the sphygmomanometer on the left ankle and position the Doppler probe over the posterior
tibial artery, which is located posterior to the medial malleolus.
2. Inflate the cuff 20-30 mmHg above the pressure at which the Doppler pulse is no longer audible
and then deflate the cuff slowly, noting the pressure at which you first detect a pulse from the
Doppler. This represents the systolic pressure in the vessel being assessed.
3. Keep the sphygmomanometer in the same location but re-position the Doppler probe over the
dorsalis pedis artery of the left foot, which is located lateral to the extensor hallucis longus tendon.
4. Assess the systolic pressure in the dorsalis pedis artery of the left foot by repeating step 2.
5. Record the highest of the two pressures obtained from dorsalis pedis (DP) and the posterior tibial
artery (PTA) for use when calculating the left ABPI.
6. Repeat the same process on the right leg to calculate the right ABPI.
Calculate ABPI
BPI
Interpretation
>1.2
Calcified vessels often cause unusually
high ABPI results. In this scenario,
further assessments such as duplex
ultrasound and angiography are
advised to accurately assess perfusion.
Left ABPI = (highest pressure of either left
PTA or DP) ÷ (highest brachial pressure)
Right ABPI = (highest pressure of either
right PTA or DP) ÷ (highest brachial
pressure)
Erroneous results can occur due to:
Incorrectly positioned cuff
Irregular pulse (e.g. atrial fibrillation)
1.0-1.2 Normal result
Mild arterial disease: typical
0.8-0.9 presenting features include mild
claudication.
0.50.79
Moderate arterial disease: typical
presenting features include severe
claudication.
<0.5
Severe arterial disease: typical
presenting features include rest pain,
ulceration and gangrene. This is also
known as critical limb ischaemia.
Calcified vessels (e.g. diabetes)
Thank you