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Approach

• Expose patient slegs from groin to toes
• Preserve dignity by keeping underwear on

1. Inspection
   • Look for signs of cardiovascular disease - cigarette smoking, diabetes
   • Look at leg / toes / between toes / feet / musculature / presence or absence of ulcers
   • Colour of skin - white / red
   • Trophic changes - loss of skin, hair, gangrene
   • Ulcers
     1. Arterial
        1. Ischaemic ulcers - found in least well-perfused areas and over pressure points (malleoli)
        2. Lesions punched out - no attempt at healing
        3. Usually smaller than venous ulcers
        4. No granulation tissue but may have thin layer of slough at base (otherwise base is flat and pale)
        5. May be very deep and penetrate surrounding tissue
        6. Commonest differential = neuropathic ulcer
        7. Look at heel (neuropathic ulcers commonest here)
     2. Venous
   • Loss of digits from previous amputations
2. Palpation
   • Feel for skin temperature - use back of hand
   • Examine toes for capillary refill
   • Palpation of peripheral pulses - rate and rhythm
     1. (check rate and rhythm of radial pulse)
     2. Femoral pulse (at mid inguinal point = halfway between the anterior superior iliac spine and pubic symphysis); compare with other side
     3. Popliteal pulse: demonstrate by compression against posterior aspect of the tibia (with knee flexed slightly) as pulse passes between two heads of gastrocnemius
     4. Foot pulses: dorsalis pedis = lateral to extensor hallucis longus tendon, posterior tibial = midway between medial malleolus and heel
   • Say you would check for AAA
3. Percussion
4. Auscultation
   • Listen for bruits over femoral artery / in subsartorial canal

Completion

1. Examine the rest of the peripheral vascular system
2. Examine abdomen for AAA
3. Measure the ankle brachial pressure indexes
   • Measure systolic BP in arm
   • Measure systolic BP in leg (with aid of doppler probe)
   • ABPI = ankle / brachial pressure
   • Normal ABPI = 1, intermittent claudication = 0.5 - 0.8, rest pain <0.5
   • Absolute pressure < 50mmHG at ankle is indicative of critical ischaemia
4. Buerger's test
   • Lift leg above level of the heart
   • At some point the perfusion drops - leg becomes white = Buerger's angle
     1. Normal leg can remain perfused at angle > 90'
     2. If angle < 20' indicates severe ischaemia
   • Drop leg over side of bed causes diseased leg to become purple-red = reactive hyperaemia (this is Buerger's test)