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1. Peripheral Vascular System
Dr Sajeda Alhamory

2. The Health History
• The purpose of the history questions is to identify symptoms of peripheral arterial and venous disease.
– Do you have pain or cramping in your legs during walking or exertion? (This is termed intermittent claudication.) (PAD)
– Do you have coldness, numbness, or pallor in the legs or feet (PAD)?
– Do you have hair on your shins (PAD)?
– Do you have aching or pain at rest in the lower leg or foot (PAD)?
– Do you have fatigue or aching in the lower legs with prolonged standing (CVI)?
– Is pain alleviated by elevating the legs (CVI)?
– Do you have swelling of the feet or legs (CVI)? Whether it is bilateral or unilateral?
– Do you have any varicose veins?
– Do you have any wounds of the legs or feet that will not heal or heal very slowly (PAD)?

3. Past History:
• Medications (oral contraceptives; hormone replacement)
• Recent pregnancy or childbirth
• Recent surgeries or fractures
• Inflammatory diseases
• Active cancer
• CAD (Coronary Artery Diseases)
• CHF
• Stroke
• Clotting disorder
• HTN
• DM
• Problems with circulation
Risk factors:
• Obesity
• Smoking
• Hyperlipidemia
• Constrictive clothing
• Central venous line

4. Family History:
• Peripheral vascular diseases
• Varicose veins
• AAA (abdominal aortic aneurysm)
• CAD
• Sudden death (younger than 60
years)
• Diabetes
Lifestyle:
• Prolonged standing/ sitting
• Sedentary lifestyle
• Decrease mobility (cast,
paralysis)
• Wearing constrictive clothing

5. ImportantAreas
of Examination
Compare your findings
with opposite extremity

6. Arms
• Inspect both arms from the fingertips to the shoulders. Note:
– Their size, symmetry, swelling, and any lesions
– The venous pattern
– The color of the skin and nail beds and the texture of the skin
• Palpate the temperature of the arms and hands simultaneously with the backs of your fingers.
Compare the temperature of the arms simultaneously.
• Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally.
Partially flexing the patient’s wrist may help you feel this pulse. Compare the pulses in both arms.
Pulses may be palpated simultaneously to facilitate comparison.

7. Radial Pulse

8. Brachial Pulse
• If you suspect arterial insufficiency, feel for the brachial
pulse. Flex the patient’s elbow slightly, and palpate the artery
just medial to the biceps tendon at the antecubital crease.
• The brachial artery can also be felt higher in the arm in the
groove between the biceps and triceps muscles

9. Epitrochlear
nodes
 With the patient’s elbow flexed to about 90° and the forearm
supported by your hand, reach around behind the arm and feel
in the groove between the biceps and triceps muscles, about 3
cm above the medial epicondyle. If a node is present, note its
size, consistency, and tenderness. Epitrochlear nodes are
difficult or impossible to identify in most normal people.
“shaking hands”

10. Evaluating the
Arterial Supply to
the Hand.
Ulnar Pulse  Feel for it deeply on the flexor surface of the wrist
medially. Partially flexing the patient’s wrist may
help you. The pulse of a normal ulnar artery,
however, may not be palpable.

11. EvaluatingtheArterial
SupplytotheHand.
Allentest
• Ask the patient to make a tight fist
with one hand; then compress both
radial and ulnar arteries firmly
between your thumbs and fingers.
• Next, ask the patient to open the hand into
a relaxed, slightly flexed position. The
palm is pale.
• Release your pressure over the ulnar
artery. If the ulnar artery is patent, the
palm flushes within 3 to 5 seconds.
Allen test used to evaluate collateral
circulation prior to cannulating
radial artery

12. • Persisting pallor indicates occlusion of the ulnar artery
or its distal branches.
• Patency of the radial artery may be tested by repeating the test and releasing the radial artery
while still compressing the ulnar artery.

13. Legs
• Uncover the legs while keeping genitalia draped
• Inspect both legs from the groin and buttocks to the feet. Note:
– Their size, symmetry, and edema. Measure leg circumferences in centimeters if discrepancy is suspected
– The venous pattern and any venous enlargement or varicosities
– Pigmentation, rashes, scars, or ulcers
– The color and texture of the skin and the color of the nail beds
– The distribution of hair on the lower legs, feet, and toes.
– Look for brownish areas (or increased pigmentation on dark-skinned clients) near the ankles. The brown
discoloration is caused by hemosiderin released from the red blood cells that seep into the skin with edema
and break down.
– Note the location, size, and depth of any ulcers in the skin. Are the edges of the wound well demarcated? Is
there bleeding?

14. Legs
– Palpate the temperature of both legs and feet simultaneously with the backs of your hands.
Compare the temperature of the legs. Skin should be warm and equal bilaterally.
– Palpate for edema. Compare one foot and leg with the other, noting their relative size and the
prominence of veins, tendons, and bones.
Edema causes swelling that may
obscure the veins, tendons, and
bony prominences.
Along legs down to feet

15. Legs
– Palpate for pitting edema. Press firmly but gently with your thumb for at least 5 seconds (1) over the dorsum
of each foot, (2) behind each medial malleolus, and (3) over the shins. Look for pitting—a depression caused
by pressure from your thumb. Normally there is none. The severity of edema is graded on a four-point scale

16. Legs
• If you suspect edema, measure the legs to identify the edema and to follow its course.
– With a flexible tape, measure (1) the forefoot, (2) the smallest possible
circumference above the ankle, (3) the largest circumference at the calf, and (4)
the midthigh, a measured distance above the patella with the knee extended.
Compare one side with the other. A difference of more than 1 cm just above the
ankle or 2 cm at the calf is unusual and suggests edema.
– If edema is present, look for possible causes
• Recent deep venous thrombosis,
• Chronic venous insufficiency from previous deep venous thrombosis or incompetence of the venous
valves
• Lymphedema.
Same number of
centimeters down
from patella or
other landmark

17. Legs
• If risk factors for DVT are present, try to identify any venous tenderness that
may accompany deep venous thrombosis.
• Very faintly palpate the groin just medial to the femoral pulse for tenderness of the
femoral vein.
• With the patient’s leg flexed at the knee and relaxed, palpate the calf. With your
fingerpads, very gently compress the calf muscles against the tibia, and search for
any tenderness or cords.
• Firm palpation or massage over a DVT may dislodge the clot, causing a pulmonary embolus or death

18. Legs
– Feel the thickness of the skin.
– Palpate areas of local redness, noting the skin temperature, and then gently
palpate for the firm cord of a thrombosed vein in the area. The calf is most often
involved.
– Palpate the pulses to assess the arterial circulation

19. Femoral Pulse
Press deeply, below the inguinal ligament and about midway between
the anterior superior iliac spine and the symphysis pubis. The use of
two hands, one on top of the other, may facilitate this examination,
especially in obese patients.
a froglike position

20.  Popliteal pulse more diffuse and difficult to localize
 Often normal popliteal pulse is impossible to
palpate
 Flex the patient’s knee to about 90°, let the lower leg
relax against your shoulder or upper arm, and press your
two thumbs deeply into the popliteal fossa.
 The patient’s knee should be somewhat flexed, with the
leg relaxed. Place the fingertips of both hands so that
they meet in the midline behind the knee and press
deeply into the popliteal fossa

21. PosteriorTibial
Pulse
 For posterior tibial pulse, curve your fingers around
medial malleolus
 Feel the tapping right behind it in groove between
malleolus and Achilles tendon

22. Dorsalis Pedis
Pulse
© Pat Thomas, 2006.
 Dorsalis pedis pulse requires a very light touch
 Normally it is just lateral to and parallel with
extensor tendon of big toe

23. Legs
• Palpate the superficial inguinal nodes, including both the horizontal and the vertical
groups. Note their size, consistency, and discreteness, and note any tenderness.
Nontender, discrete inguinal nodes up to 1 cm or even 2 cm in diameter are
frequently palpable in normal people.

24. Legs
• At the end of the examination, ask the patient to stand,
and inspect the saphenous system for varicosities.
• The standing posture allows any varicosities to fill with
blood and makes them visible. You can easily miss them
when the patient is in a supine position.
• Feel for any varicosities, noting any signs of
thrombophlebitis

25. Evaluating Arterial Supply to the Legs.
• If pain or diminished pulses suggest arterial insufficiency, look for Postural Color Changes.
– With the patient lying down, raise both legs, as shown to about 60° until maximal pallor of the feet develops—usually
within a minute. Have the patient flex the ankles up and down to drain venous blood. In light-skinned persons, either
maintenance of normal color, as seen in this right foot, or slight pallor is normal. In dark-skinned persons, evaluate the
soles of the feet or nail beds for pallor.
– Then ask the patient to sit up and dangle the legs over the side of the examination table. Compare both feet, noting the time
required for:
• Return of pinkness to the skin, normally about 10 seconds or less
• Filling of the veins of the feet and ankles, normally about 15 seconds
• Look for any unusual rubor (dusky redness) to replace the pallor of the dependent foot. Rubor may take a minute or
more to appear.