OnExam

Vital Signs

Assess vital signs.

Inspection

Arms

  • Ensure proper draping, allowing inspection from the shoulders to the fingertips or both arms.
  • Take special note of:
    • Size and symmetry of both arms
    • Edema
    • Venous pattern or distension
    • Colour and texture of the skin and nail beds
      • Nicotine stains
      • Raynaud’s disease: affected areas (fingertips) can turn white or blue due to insufficient blood flow to distal arteries
    • Clubbing
    • Skin chatacteristics
      • Rashes, ulcers, or scars
      • Petechiae or purpura
      • Hair distribution
    • Muscle Atrophy

Legs

  • Ensure proper draping, allowing full inspection of the legs from the groin to the tips of the toes while covering the external genitalia.
  • Inspect the legs and buttocks from the groin to the feet taking note of:
    • Size and symmetry of both legs
    • Edema
    • Venous pattern or distension
    • Colour and texture of the skin and nail beds
      • Abnormally pale, red or blue foot for PVD
        • Sensitivity 35%, Specificity 87%
        • LR+ 2.8 and LR- 0.7
    • Skin chatacteristics
      • Rashes, ulcers, or scars
      • Petechiae or purpura
      • Hair distribution
      • Presence of atraumatic wounds or sores on the foot for PVD
        • Sensitivity 2% and specificity 100%
        • LR+ 7.0 and LR- NS
    • Hemosiderin deposition
    • Clubbing
    • Muscle atrophy

Palpation

Axial

  • Palpate carotid pulse bilaterally, noting:
    • Rate
    • Rhythm
    • Amplitude and any variations in amplitude
    • Timing of upstroke in relation to S1 and S2
    • Presence of thrills (if present, auscultate for bruit)
  • Palpate the abdominal aorta noting its size
    • Normal: <3cm

Arms

  • Feel the temperature of the arms and hands, comparing one side to the other.
  • Test capillary refill
    • Average time is 2-3 seconds
  • Palpate the following pulses in each arm, noting any differences between the two sides:
    • Brachial Pulse: Brachial artery at the bend of the elbow, just medial to the biceps tendon
    • Radial Pulse: Radial artery on lateral flexor surface near the wrist.
  • Consider grading the pulses on a scale:
    • 0 = Absent or unable to palpate.
    • 1+ = Weak or diminished pulse.
    • 2+ = Brisk, pulse is as expected.
    • 3+ = Bounding pulse.
  • Palpate for epitrochlear nodes between the biceps and triceps muscles
    • Flex patient's arm to 90° for better access
    • Enlarged node may be indicative of insufficient drainage
  • Consider doing an Allen’s Test

Legs

  • Feel the temperature of the legs and feet, comparing one side to the other.
    • Asymmetrically cooler foot in PVD.
      • Sensitivity 10% and Specificity 98%
      • LR+ 6.1 and LR- 0.9
  • Test capillary refill
    • Average time is 2-3 seconds
    • Capillary refill time of equal to or greater than 5 seconds in the great toe is indicative of PVD
      • Sensitivity 28% and specificity 85%
      • LR+ 1.0 and LR- NS
  • Check for pitting edema
    • Press firmly with your thumb for at least five seconds in the following locations of each lower extremity:
      • The dorsum of each foot
      • Behind the medial malleolus
      • Over the shins
    • Note the presence, degree of pitting (depression formation) and the most proximal point of edema (e.g. extending to the knees) to identify the location of possible occlusion
    • Grade the edema on a 4 point scale:
      • From slight (1+) to very marked (4+)
      • No pitting is normal
  • Consider taking a measurement of the edematous legs:
    • Useful to compare one leg to the other, and the same limb to itself at various time points
      • Difference >1cm near ankle or >2cm at calf suggests edema
    • Using a measuring tape, obtain circumference from:
      • The forefoot
      • Smallest possible circumference near the ankle
      • Largest calf circumference
      • Midthigh with knee extended and measured upward from patella
  • Evaluate veins
    • Palpate femoral vein and veins of the calf
    • Note any abnormalities, including:
      • Tenderness suggestive of deep vein thrombosis
      • Prominence or distension for venous etiology of edema
      • Cords
  • Palpate the following pulses in each leg, noting any differences between the two sides:
    • Femoral pulse: Femoral artery in groin region, approximately below the mid-point of the inguinal ligament
      • Absent femoral pulses in PVD
        • Sensitivity and specificity for peripheral vascular disease have been found to be 7% and 99%, respectively
        • LR+ 6.1 and LR- NS
    • Popliteal pulse: Popliteal artery as it passes posterior to the knee in the popliteal fossa
      • Effectively found by laying the patient supine and holding the knee slightly flexed, with both fingertips lightly in the fossa
    • Dorsalis pedis pulse: Dorsalis pedis artery on dorsal surface of the foot, lateral to the extensor hallucis longus tendon
    • Posterior tibial pulse: Posterior tibial artery as it passes just posterior and inferior to the medial mallelous
      • Absent dorsalis pedis and posterior tibial pulses in PVD
        • Sensitivity 63-72% and specificity 92-99%
        • LR+14.9 and LR- 0.3 (Best screening for PVD)
  • Consider grading the pulses on a scale
    • 0 = Absent or unable to palpate.
    • 1+ = Weak or diminished pulse.
    • 2+ = Brisk, pulse is as expected.
    • 3+ = Bounding pulse.
  • In general:
    • Weakened/absent pulse in occlusion proximal to this site
    • Exaggerated/widened pulse in aneurysm
  • Consider performing a diabetic foot exam
  • Consider mapping varicose veins
  • Consider performing a Buerger's test
  • To evaluate the competency of the valves of the venous system consider completing a Trendelenburg Test

Auscultation

  • Using the diaphragm of a stethoscope, listen to the carotid arteries for a bruit.
    • Especially if the patient is middle aged, elderly, or cerebrovascular disease is suspected
    • Breath sounds may obscure proper carotid auscultation
    • Auscultation of the carotid arteries may also reveal severe, radiating heart murmurs
  • Using the diaphragm of the stethoscope, listen for bruits over the aorta, renal arteries, iliac arteries, and femoral arteries.
    • Note whether the bruit occurs only during systole or if it has both systolic and diastolic components.
    • Presence of bruit for PVD
      • Sensitivity 20-50% and specificity 95-99%
      • LR+ 7.3 and LR- 0.7

Clinical Usefulness

Clinical findings suggestive of PVD
Inspection
  • Wounds or sores on foot
    • +LR 7
  • Foot colour abnormally pale, red or blue
      +LR 2.8, -LR 0.7
Palpation
  • Foot asymmetrically cooler
      +LR 6.1, -LR 0.9
  • Absent femoral pulse
      +LR 6.1
    • Absent posterior tibial and dorsals pedis pulses
        +LR 14.9, -LR 0.3

  • Auscultation
    • Limb bruit present
        +LR 7.3, -LR 0.7

References

  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
  2. Bitar R, Jugovic P, McAdam, L. Fundamental Clinical Situations: A Practical OSCE Study Guide 4th Edition. Toronto, ON, Canada: Elsevier Canada; 2004.
  3. Filate, W, Leung, R, Ng, D, Sinyor, M. Essentials of Clinical Examination Handbook 5th Edition. Toronto, ON, Canada: The Medical Society Faculty of Medicine University of Toronto; 2005.
  4. McGee S. Evidence-Based Physical Diagnosis. Philadelphia, PA: Saunders, 2001.