Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Leg pain |
Intermittent claudication |
Older male patient, may have family history of PAD.
Risk factors: smoking, alcohol, low exercise, obesity, stress. Co-morbidities: diabetes, hypertension, CKD. Cramping pain in legs after walking a certain distance. Improves with rest, no rest pain. Stigmata of peripheral arterial disease in lower limbs e.g., weak peripheral pulses, missing limbs or digits, scars. |
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Chronic limb-threatening ischaemia |
Risk factors, co-morbidities and demographics as above.
>2 weeks of gradually worsening limb pain including at rest. Reduced/absent pulses, skin pink/warm to touch. Ulcers. |
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Acute ischaemic limb |
Risk factors, co-morbidities and demographics as above.
Sudden onset of the 6 Ps: Pale, Pulseless, Painful, Paralysis, Paraesthesia, Perishingly cold. |
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| Leg/foot ulcer |
Arterial ulcer |
Risk factors for peripheral arterial disease as above.
May have PAD symptoms e.g., claudication, weak pulses. Arise distally, peripheral circulation poor: toes, dorsal foot. Small, painful, punched out, well demarcated, deep, pale. Pain worse on elevation of leg due to poor arterial supply. |
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Venous ulcer |
Associated with chronic venous skin changes e.g., Eczema.
Arise in gaiter region just above the ankle/below calf. Larger, less painful, irregular edges, superficial, bleeding. Pain improved with leg elevation: relief of venous pressure. |
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Neuropathic ulcer |
Common in patients with known neuropathy e.g., diabetes.
Poor sensation so unaware of injury/friction to feet. Located at pressure points on foot e.g., heel. Painless, peripheral. Foot will be well perfused unless concurrent PAD. |
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| Pulsatile abdominal mass |
Abdominal aortic aneurysm (AAA) |
Older male patient, smoker, hypertension, family history.
Majority asymptomatic, possible non-specific abdo pain. May be found on routine screening (men), incidental finding. Pulsatile, expansile mass in abdomen. Clinically well. |
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Ruptured AAA |
Very unwell patient, haemodynamic instability.
Severe abdominal pain radiating to back or pelvis. Pulsatile and expansile mass in abdomen. May be associated with collapse & loss of consciousness. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient reclining 45° | ||
| Appropriate exposure of upper/lower limbs & abdomen | ||
| General Inspection | Body habitus | |
| Presence of all limbs/digits | ||
| Discoloured limbs/digits | ||
| Obvious scars | ||
| Walking aids or prostheses | ||
| Clues in bed space | ||
| Hands | Colour | |
| Tar staining | ||
| Tendon xanthomata | ||
| Temperature | ||
| Capillary refill | ||
| Arms | Colour | |
| Temperature | ||
| Radial pulse | ||
| Radio-radial delay | ||
| Radio-femoral delay (offer) | ||
| Brachial pulse | ||
| Blood pressure (offer) | ||
| Neck | Auscultate carotid pulse | |
| Palpate carotid pulse | ||
| Eyes | Xanthelasma | |
| Corneal arcus | ||
| Abdomen | Scars | |
| Visible pulsation | ||
| Palpation of aorta | ||
| Auscultation of aorta | ||
| Auscultation of renal arteries | ||
| Legs | Colour | |
| Skin changes | ||
| Scars | ||
| Ulcers | ||
| Temperature | ||
| Femoral pulse (offer) | ||
| Auscultation of femoral artery (offer) | ||
| Popliteal pulse | ||
| Sensation | ||
| Feet | Colour | |
| Presence of all digits | ||
| Ulcers | ||
| Temperature | ||
| Capillary refill | ||
| Posterior tibial pulse | ||
| Dorsalis pedis pulse | ||
| Sensation | ||
| Special Tests | Buerger’s test | |
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your peripheral arterial system. This involves looking at your arms, abdomen and legs. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient reclined on the examination couch at 45°.
Ask the patient to expose their upper limbs, lower limbs and abdomen (e.g., examine in shorts and bra if applicable).
General Inspection
Look at the patient and around the bed space for useful signs:
- Body habitus (e.g., overweight or underweight)
- Presence of all limbs or digits – missing limbs/digits may indicate previous amputation
- Discoloured limbs or digits – may indicate ischaemic changes
- Obvious scars visible from the end of the bed
- Walking aids or prostheses
- Clues around the bed space (e.g., oxygen, cigarettes, medication)
Hands
Examine both hands together noting:
- Colour (e.g., pale/mottled indicates poor peripheral perfusion, blue tinge to fingertips in peripheral cyanosis)
- Tar staining
- Tendon xanthomata may indicate hyperlipidaemia, increasing the risk of peripheral arterial disease
- Temperature (e.g., cold hands may indicate poor peripheral perfusion)
- Capillary refill time at the fingertip
Arms
Inspect the general appearance of the arms and then assess pulses:
- Colour (e.g., pale, mottled)
- Temperature
- Radial pulse
- Radio-radial delay
- Radio-femoral delay (offer this in exam setting)
- Brachial pulse
- Blood pressure (offer this in exam setting)
When palpating the radial pulse, the rate (beats per minute), rhythm (regular or irregular), character (e.g., slow rising) and volume (bounding, thready) of the pulse should be assessed. Assess for radio–radial delay by palpating both radial pulses simultaneously and feeling for synchronicity. Offer to examine for radio–femoral delay by palpating both the radial and femoral pulse at the same time. A radio–radial or radio–femoral delay is abnormal and may indicate aortic coarctation or dissection.
Palpate the brachial pulse; found approximately 2 cm supero-medial to the the biceps tendon when palpated in the ante–cubital fossa. Offer to measure blood pressure in both arms.
Neck
Examine the neck for:
- Carotid pulse
Always assess carotid pulse one side at a time; never palpate both sides simultaneously. Assess the carotid pulse by first auscultating for bruits then palpating the pulse (character, volume). If bruits are present do not palpate the carotids due to increased stroke risk.
Eyes
Look at the patient’s eyes examining for:
- Xanthelasma indicating hyperlipidaemia
- Corneal arcus indicating hyperlipidaemia
Abdomen
Inspect the abdomen for:
- Scars indicating previous surgery (e.g., abdominal aortic surgery)
- Visible pulsations
Palpate the abdomen for:
- Abdominal aorta (pulsatile or expansile)
Auscultate for:
- Aortic bruits
- Renal bruits
Palpate the abdominal aorta. Place both hands on the patient’s abdomen, with palms facing down and positioned vertically approximately 2 cm apart either side of the midline between the umbilicus and the xiphisternum. Feel for a palpable pulsation of the abdominal aorta. If a pulsation is felt and your hands move upwards only with each pulsation this may indicate a normal variant commonly seen in slim patients. If your hands move outwards with each pulsation, this indicates an expansile aorta, which is abnormal and concerning for abdominal aortic aneurysm (AAA).
Auscultate the abdominal aorta for bruits. Then auscultate over the renal arteries for bruits; located approximately 2 cm above the umbilicus either side of the midline. If a renal bruit is heard this may indicate renal artery stenosis.
Legs
Examine both legs together noting on inspection:
- Colour (e.g., pale, mottled)
- Skin changes (e.g., hair loss, shiny skin indicate chronic peripheral arterial disease)
- Scars from previous surgery (e.g., bypass)
- Ulcers – arterial ulcers are typically small, painful, punched-out, deep and well defined
Palpate the legs, checking:
- Temperature – cooler peripheries may indicate poor circulation
- Femoral pulse (offer this in exam setting but be prepared to demonstrate)
- Popliteal pulse
- Sensation – chronic peripheral arterial changes may cause peripheral neuropathy
The femoral artery is located at the mid–inguinal point, half-way between the ASIS and the symphysis pubis. Palpate the femoral pulse and auscultate for femoral bruits; if present bruits may indicate stenosis of the femoral artery.
The popliteal pulse is known for being difficult to palpate;, if you cannot feel it, be honest about this. To palpate the popliteal pulse place both hands around the patient’s knee with thumbs anterior on the tibial tuberosity and fingers posterior in the popliteal fossa. Flex the patient’s knee to around 30° and ask them to relax. The pulse should be palpable in this position.
Feet
Inspect both feet together for:
- Colour (e.g., pale, mottled)
- Presence of all digits
- Ulcers
Palpate the feet, checking for:
- Temperature – cooler peripheries may indicate poor circulation
- Capillary refill time of toe
- Dorsalis pedis pulse
- Posterior tibial pulse
- Sensation – chronic peripheral arterial changes may cause peripheral neuropathy
The dorsalis pedis pulse is palpated on the dorsal aspect of the foot. Ask the patient to flex their great toe and place fingers just lateral to the extensor hallucis longus tendon at the level of the metatarsal bones. The posterior tibial pulse is located at the medial ankle; at the half–way point between the medial malleolus and the achilles tendon.
Special Tests
The key special test in the peripheral arterial examination is Buerger’s test. With the patient reclined, slowly lift one leg and observe for any colour change. The test is negative if the foot remains pink and well perfused through 90°. If the foot becomes pale then the test is positive and indicates peripheral arterial disease; the angle of onset of pallor is Buerger’s angle. The test can be extended by observing any reactive hyperaemia when the pale foot is lowered and dangled over the side of the couch; the test is positive if the foot becomes markedly red and again indicates peripheral arterial disease.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings, you may wish to carry out further investigations, including Ankle Brachial Pressure Index (ABPI), Doppler ultrasound, or blood tests to identify risk factors for arterial disease (e.g., hyperlipidaemia).
Last updated Dec 2024
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