A systematic peripheral arterial examination (or vascular exam) is used to assess the adequacy of the blood supply to the limbs.
It is crucial for diagnosing Peripheral Arterial Disease (PAD), acute limb ischemia, or complications related to diabetes.
Before assessing the vasculature, ensure the patient is comfortable and the environment is warm (cold temperatures cause vasoconstriction):
W – Wash: Clean your hands using the WHO 7-step technique.
I – Introduce: State your name and role.
P – Permission & Pain: Explain that you will be checking pulses and blood flow in the legs. Ask if they have any pain in their calves or feet at rest.
E – Exposure: The patient should be exposed from the waist down (retaining underwear).
R – (Re)position: The patient should lie supine on the examination couch.
Observe the legs and feet for signs of chronic or acute ischemia:
Pallor: Pale skin or a “waxy” appearance.
Perished with Cold: Note the temperature (using the back of your hand later).
Pulselessness: (To be assessed during palpation).
Paresthesia & Paralysis: Suggests advanced, limb-threatening ischemia.
Pain: Specifically looking for signs of “rest pain.”
Other Visual Markers:
Trophic Changes: Hair loss, thin/shiny skin, and thickened nails (signs of chronic PAD).
Ulceration: Arterial ulcers are typically “punched out,” painful, and found on the toes or heels.
Gangrene: Black, necrotic tissue (dry or wet).
Scars: Look for previous femoral-popliteal bypass grafts or amputations.
Assess the temperature and pulses systematically from proximal to distal.
Temperature & Capillary Refill
Temperature: Use the back of your hand to compare the temperature of both legs. A cool limb suggests poor arterial supply.
Capillary Refill Time (CRT): Compress the pulp of the big toe for 5 seconds. Normal return of color should be $<2$ seconds.
Pulse Assessment
You must assess the following pulses bilaterally:
Femoral: Located at the mid-inguinal point (halfway between the ASIS and pubic symphysis).
Popliteal: Found in the popliteal fossa. Ask the patient to slightly flex the knee; use both hands to “hook” into the fossa.
Posterior Tibial: Located posterior and slightly inferior to the medial malleolus.
Dorsalis Pedis: Located on the dorsum of the foot, lateral to the extensor hallucis longus tendon.
Listen for bruits (sound of turbulent flow caused by narrowing/stenosis) using the diaphragm of your stethoscope over:
The Aorta (above the umbilicus).
The Renal Arteries (bilaterally).
The Femoral Arteries (at the mid-inguinal point).
Buerger’s Test
With the patient supine, elevate both legs to 45° for 1–2 minutes. Look for pallor (indicates poor arterial supply).
Ask the patient to sit up and hang their legs over the edge of the bed.
Observe for reactive hyperemia (the leg turns “sunset red”). This is a positive Buerger’s test, indicating significant PAD.
Ankle-Brachial Pressure Index (ABPI)
State that you would measure the ABPI using a Doppler probe.
To finish your OSCE vascular assessment, state you would:
Examine the Sensation: Check for “glove and stocking” anesthesia (diabetic neuropathy).
Abdominal Exam: Specifically palpate for an Abdominal Aortic Aneurysm (AAA).
Cardiovascular Exam: PAD is a marker of systemic atherosclerosis; check the heart and carotids.
Review the Chart: Check for smoking status, blood glucose (diabetes), and cholesterol levels.
| Feature | Arterial Disease | Venous Disease |
| Pain | Intermittent claudication or rest pain | Aching, “heavy” sensation |
| Pulses | Weak or absent | Usually normal |
| Skin | Cool, shiny, hairless | Warm, thickened, stained (hemosiderin) |
| Ulcers | Deep, “punched out,” distal | Superficial, irregular, gaiter area |
For a visual guide to Buerger’s test and pulse palpation:
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