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1. Introduce yourself, gain consent and wash your hands

2. Inspection

• Make the patient comfortable, expose their lower limbs and look for abnormalities:

 

Sign	Details
abnormal colouration	pale colour may indicate arterial claudication. blue/dusky/black colour can indicate severe limb ischaemia.
hair loss	occurs in peripheral vascular disease
muscle wasting	occurs in chronic limb ischaemia
scars	may indicate previous vascular surgery or trauma
thin dry skin	may indicate peripheral vascular disease
varicosities	dilated tortuous veins
ulcers	can be arterial or venous ulcers. Look particularly at pressure points and between toes.

 

3. Palpation

• Temperature (note if the limb becomes cold distally and if there is a clear point of change).
• Capillary return (normal <2s).
• Feel for pulses:

 

Pulse	Method for palpation
popliteal	Flex knee to 30°, place both thumbs below the patella and use 8 fingers to press in the popliteal fossa below the knee crease in the midline. An easily palpable popliteal pulse may be aneurysmal.
posterior tibial	Found 2cm below and 2 posterior to the medial malleolus.
dorsalis pedis	Found on the dorsum of the foot, just lateral to the tendon of extensor hallucis longus.
femoral	Found below the inguinal ligament at the mid-inguinal point (halfway between the anterior superior iliac spine and the pubic symphysis).

Compare pulses on both sides for symmetry and record as + normal; ± reduced; – absent or ++ aneurysmal. Feel specifically for radio-femoral delay (delayed pulse in one femoral artery) which suggests coarctation of the aorta.

 

4. Auscultation

Listen for bruits over the femoral and iliac arteries

 

5. Abbreviated abdominal examination

• Observe the abdomen from the side, eyes level with the patients abdomen, for pulsations which may indicate an abdominal aortic aneurysm.

• Check the patient has no abdominal pain before performing a deep palpation in all four quadrants for pulsatile masses (abdominal aortic aneurysm and iliac aneurysms).

 

6. Further tests

• Buerger's Test: Raise each leg to 45° from horizontal and support at this angle for 2 minutes then hang the leg over the edge of the bed to allow blood to return to the limb. Pallor on elevation with subsequent dusky redness on dependency (reactive hyperaemia) is defined as a positive result and indicate ischaemia. Also observe for venous guttering on elevation, also indicative of arterial insufficiency.
• Ankle Brachial Pressure Index (ABPI): Is defined as the ratio of systolic blood pressure in the arm compared to the leg:

• Result > 0.9 is normal, 0.9-0.5 moderate ischaemia, >0.5 severe ischaemia

 

7. Cover the patient up and thank them