Temperature – feel the temperature with the back of your hand (cool = reduced peripheral perfusion)
Capillary refill – press down for 5 seconds with your fingertip and count how long it takes to reperfuse (should be <2 seconds)
Pulses
Radial pulse
Radio-radial delay (aortic dissection/aneurysm or proximal coarctation)
Offer to test for radio-femoral delay (aortic coarctation); brachial pulse; and blood pressure in both arms (>10mmHg difference = significant and suggests aortic dissection, proximal coarctation or subclavian artery stenosis)
Eyes: look at the eyes for corneal arcus and xanthelasma (hyperlipidaemia)
Mouth: look under the tongue for central cyanosis
Carotid pulse: feel the character and auscultate for bruits (carotid artery stenosis)
Abdomen
Inspection: body habitus, scars, visible aortic pulsation
Aortic and femoral pulses: palpate pulses, auscultate for bruits (‘machinery’ aortic bruit = AAA)
How to… Palpate the aorta
Press down with your finger tips (one hand each side) in the horizontal plane midway between the umbilicus and xiphoid process, starting laterally and moving medially
The ulnar borders of your hands should be parallel with the costal margins
A pulsatile mass, i.e. upward movement, can be normal
An expansile mass, i.e. outward movement, suggests AAA
Lower limbs (main part)
Check for pain in legs. Examine with patient standing and then lying supine.
Inspection (especially feet)
Skin colour changes (pink, pale, mottled)
Ischaemic changes: especially between toes and heels – don’t miss toe amputations!
With patient lying supine, lift their leg until heel becomes pale then hold for 30 seconds (if it does not become pale, test is normal; if it becomes pale, the degree of hip flexion is Buerger’s angle)
Now ask patient to sit up and hang their legs over the edge of the bed
Watch their feet for 2-3 minutes
Pallor followed by reactive hyperaemia (rubor) on dependency is a positive test and implies significant peripheral arterial disease
To complete
Thank patient and restore clothing
‘To complete my examination, I would perform a full cardiovascular examination, test sensation, and use Doppler ultrasound to further assess pulses.’
Summarise and suggest further investigations you would consider after a full history (e.g. ABPI, duplex USS, MR or CT angiography, catheter angiography, bloods, ulcer swabs, ECG, HbA1C etc.)
How to… Measure ABPI using Doppler
Measure the brachial SBP of both arms (place the Doppler probe at 45˚ over the brachial artery, inflate the cuff over the upper arm until the Doppler signal stops, then gradually deflate it – the SBP is the cuff pressure at which the Doppler signal returns)
Measure the ankle SBP of both legs (repeat the above procedure but with the cuff around the lower shin and the Doppler probe over the dorsalis pedis or posterior tibial artery)
Right ABPI = right ankle SBP / highest brachial SBP from either arm
Left ABPI = left ankle SBP / highest brachial SBP from either arm
