Vascular examination sheet

As any local exam you have to start with brief general exam to assest your
patient's condition
The initial approach is to introduce yourself to the patient, explain what
you are going to do & take permission, insure privacy, wash and warm your
hands
Then put the patient in the his/her ideal position which is supine position
for lower limb exam
The typical exposure for this exam is below the umblicus! To look for
inguinal lymph nodes, but because of the morals expose below the mid
thighs
Before you start exam Ask the doctor if he wants you to take a focused
history from the patient! Please do not forget to Ask!

Starting by general exam

1) Comment on the patient sex& age!
2) Is he concious, alert, oriented?
3) Is he in respiratory distress! So look for SiGns of Respiratory
distress(cyanosis, air hunger, use of accessory muscles, nasal flaring, RR!)
4) His position!
5) Body built!
6) Colors! Cyanosed, pale, jaundiced?
7) Any devices attached! Canula, oxygen mask, nasogastric, follys catheter

This is simlpe & mundane for all examinations

Now by local exam which is compsed of

inspection, palpation, auscaltation, special tests &neurological exam

By inspection
1) Look for asymmetry of both limbs, identefying which limb is larger

Before starting commenting please look for the limb dorsal aspect from below by
asking the patient to raise His both limbs Start commenting for the positive
findings then mention all the negative SiGns

Measure both limb girths at the same level, e.g 20 cm below the tibial tubersity, if
the differance is less than 3 cm for the dominant limb, this is normal, but if more
than 3 cm so there is abnormality
2) Look for erythema, abnormal discoloration, bruising , any deformity,
amputated fingers,
3) Scars, descriping it well, its site, shape, length, type of healing
4) Trophic changes as shiny skin, loss of hair, interdigital fungal infection ,
&finger changes
5) Dilated veins (varicose veins)
6) If there Ulcer comment as following
a) Number (single or multiple) if multiple describe the largest one
b) , site,
c) size,
d) shape,
e) skin surrounding(erythema, abnormal discoloration, swelling) ,
f) floor (granulation tissue or NECROTIC),
g) edge (slopping (healing Ulcer), punched out (Active Ulcer) for exam, others
can be rolled for BCC, everted for SCC, undermined For TB),
h) discharge (pus, blood, serous)

By palpation
1) Temperature& tenderness,
2) Edema,
3) pulses,
4) Ulcer ,
5) inguinal lumph nodes,
6) capillary refilling

1) Compare both limbs if such one of them is cold or hot & tenderness
2) Identify the stage and grade of the Edema if it's pitting Stating against
navicular bone, malleolus, tibial shaft and so on, you can Start from above
downward!, the important thing is to compress against hard surface
3) Feel the pulses
a. dorsalis pedis puls, lateral to tendon of extensor hallusis longus in
the proximal third between the medial & lateral malleoli
b. Posterior tibial, mid way between medial malleolus and the heel
c. Popliteal artery at 135 degree by your fingers and the thumbs on the
patella
d. Femoral pulse at the mid inguinal point
4) Palpate the superficial inguinal nodes
5) Do the capillary refilling time normally accepted to 2-3 seconds
 6) For the Ulcer

a) Temperature & tenderness

b) Those of inspection plus
c) Margin indurated (thick & hard)or not
d) Base mobile or not
e) Squeezing if there discharge or not

Auscaltation
for bruie of femoral, dorsalis pedis, & posterior tibial arteries

The special tests

(ankle brachial index, burger angle, venous refilling time)

1) ABI /measure systolic BP above ankle, and brachial,Then if the ratio

between 0.9-1.1 this normal, if less indicates lower limb ischemia,the
critical lower limb ischemia is less than 0.4
2) Burger angle /Ask the patient to raise his leg normally to 90 without change
in color, if less than 20 degree this is critical (inversely proportional)
3) Venous refilling time / after the patient lay down his leg at the bed, look
when do the vein refill, normally it takes 15-30 secs, if more so there is
abnormality.
4) There is dependency test!

Neurological examination(motor & sensory)

1) Motor /Ask the patient to doriflex his ankles, flex and extend other joints
2) Sensory by pin, and the patient's eyes closed

Cover the patient and thank him

Q1/ what are the factors that contribute to develop diabetic foot in
diabetic patient
1) Atherosclerosis,
2) Peripheral neuropathy,
 3) and immunocompromised state.

The glucose is neurotoxic, good media for infection, has a role in

Atherosclerosis After any trauma, no blood supply for healing, so easily
develops Ulcer, necrosis, & gangrene .

Q2/ what is critical limb ischema?

)1 ABI < 0.4 or 0.85 in diabetic

2) Burgers angle < 20

By / Dr. Tareq Mhani Tareq Mhani

W/B Oday