1. Preparation

1. Wash your hands prior to examining the patient.
2. Have the patient put on a gown. This examination should never occur through clothing.
3. Check the blood pressure in both arms.

2. The Upper Extremities

1. Have the patient lie supine on the exam table, with the head raised to a comfortable position.
2. Begin with inspection by exposing the entirety of both arms. Note symmetry, color, hair pattern, size, skin changes, nail changes, varicosities, muscle wasting, and trauma (Table 1).
3. Palpate by using the back of the fingers to assess skin temperature. Examine from distal to proximal, comparing one side to the other.
4. Assess capillary refill by applying firm pressure over the distal 1st or 2nd digit for 5 sec. Release pressure and count how many seconds it takes for the normal skin color to return. A normal capillary refill time (CRT) is less than 2 sec, and values greater than 5 sec increase the likelihood of vascular disease. Additionally, CRT may be prolonged in hypovolemia and cooler ambient temperatures.
5. Palpate for edema over the dorsum of the hands using firm pressure for at least 2 sec. If present, palpate proximally, noting the extent and distribution of the edema, and whether or not it is pitting. Grade the edema as trace, mild, moderate, or severe.
6. Palpate the major arteries and note the symmetry, the intensity, and the regularity of the pulse. Useful terminology to describe the pulse intensity includes absent, diminished, normal, or bounding. If unsure, compare the patient's pulse to your own pulse. Use anatomical landmarks to find the pulse. If no pulse is felt, vary the pressure, then adjust your position, as there is variability in the path of each artery.
   1. Palpate the radial arteries, which lie lateral to the flexor carpi radialis tendon.
   2. Palpate the ulnar arteries, which are just lateral to the flexor carpi ulnaris tendon.
   3. Palpate the brachial arteries in the antecubital fossa, medial to the biceps tendon. The artery can be followed proximally in the medial groove between the biceps and triceps muscles.

3. The Abdomen

1. Lower the head of the table so the patient is lying flat.
2. Inspect the abdomen for dilated veins. Dilated veins around the umbilicus may be due to portal hypertension or obstruction of the inferior vena cava (IVC).
   1. For dilated superficial veins, determine the direction of filling by using a finger to compress the vein proximally.
   2. Use a second finger to strip the blood distally from the vein and then leave the finger in place, thus compressing two points along the flattened vein.
   3. Remove the proximal finger and note the speed at which the vein refills.
   4. Repeat the process; however, remove the distal finger and compare the filling speed. Note the direction of the fast filling, which is away from the source of venous hypertension.
3. Palpate for the abdominal aorta, just above the umbilicus and slightly left of the midline. Use 3 to 4 finger pads of both hands to apply slow and steady downward pressure. The hands should point cephalad and slightly toward each other.
4. Once the pulse is encountered, gradually bring the fingertips closer together until the lateral walls of the aorta are felt. Measure the distance between the fingers.
5. Next,auscultatefor bruits using the diaphragm of the stethoscope, applying moderate pressure. A bruit with a systolic and diastolic component is more likely to be pathologic than a systolic bruit alone.
   1. Auscultate the renal arteries above the umbilicus and 1" to 2" lateral to the midline.
   2. Auscultate the abdominal aorta above the umbilicus and to the left of the midline.
   3. Auscultate the iliac arteries below the umbilicus and 1" to 2" lateral to the midline.

4. The Lower Extremities.

1. Begin with inspection by exposing the entirety of both legs, but leave the genitalia covered. Look for changes as described in Step 2.2 and Table 1.
2. Palpate for temperature, CRT, edema, and arteries, as described in Step 2.3.
3. Palpate the dorsalis pedis (DP) arteries, just lateral to the extensor hallucis longus tendon. One or both DP arteries may be congenitally absent in a small percentage of patients.
4. Palpate the posterior tibialis (PT) arteries at the posterior-inferior aspect of the medial malleolus.
5. Palpate the popliteal arteries, beginning with the leg slightly flexed at the knee. Place both thumbs on the patellar ligament and wrap your fingers around the knee, such that the fingertips land in the middle of the popliteal fossa. If there is difficulty identifying the pulse, gradually flex the knee in 15° intervals while continuing to palpate. If unable to encounter the pulse in this position, have the patient turn to the prone position, flex the knee, and support the lower extremity. Place your hands on either side of the knee and use the thumbs to palpate the popliteal artery.
6. Palpate the femoral arteries, just inferior to the inguinal ligament, approximately midway between the anterior superior iliac spine and the symphysis pubis.
7. Auscultate the femoral arteries using the bell or diaphragm of the stethoscope, using light pressure, so as not to artificially induce a bruit.

Table 1. Skin changes associated with peripheral vascular disease.

5. Special Maneuvers

1. Use the Allen test prior to cannulating the radial artery to ensure adequate collateral flow through the palmar arch from the ulnar artery.
   1. Begin by palpating the ulnar and radial arteries on the side.
   2. Ask the patient to make a tight fist.
   3. Apply sufficient pressure over the ulnar and radial arteries to occlude them.
   4. Ask the patient to open the fist, and note the pallor of the palm.
   5. Release the ulnar artery. If sufficient collateral flow is present, the palm should become pink again within 3 to 5 sec.
2. Use Buerger's test to assess for PAD of the lower extremities, and it may also be useful for predicting the severity of the disease. With the patient supine, elevate the legs to 60° for 2 min or until the pallor of the distal extremity is noted.
   1. Lower the legs and allow them to dangle below the table's edge. Observe for 2 min or until a hyperemia is observed over the dorsum of the foot, indicating arterial insufficiency.
3. Perform the following maneuvers in patients with varicose veins to localize the site of incompetent valves.
   1. Perform the Brodie-Trendelenburg test with the patient in the supine position.
      1. Elevate the leg of interest and strip the blood proximally out of the great saphenous vein (GSV).
      2. Compress the GSV just below the sapheno-femoral junction (SFJ), and ask the patient to stand.
      3. Observe the filling of the GSV, which under normal circumstances, fills distal to proximal and takes 20 to 30 sec. Rapid filling with the GSV occluded suggests insufficiency of the perforating veins.
      4. Release the pressure over the GSV. Accelerated filling suggests venous insufficiency at the level of the SFJ.
   2. Perform the cough test to detect reflux at the SFJ. With the patient standing, palpate over the SFJ with light pressure.
      1. Instruct the patient to cough. A palpable thrill suggests retrograde flow and venous insufficiency.
   3. To perform the Perthes test, place a tourniquet around the leg, just below the knee.
      1. Instruct the patient to perform 10 heel raises. Emptying of the varicose veins suggests incompetence above the level of the tourniquet (SFJ, sapheno-popliteal junction, or thigh perforating veins). If the veins remain distended, the site of insufficiency is the calf perforating veins.