Seidel’s Physical Examination Handbook

Technique	Findings
Peripheral Arteries
Palpate arterial pulses in neck and extremities
Palpate carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries, using distal pads of second and third fingers, as shown in figures below and on p. 117.
• Characteristics Compare characteristics bilaterally, as well as between upper and lower extremities.	EXPECTED: Femoral pulse as strong as or stronger than radial pulse.
	UNEXPECTED: Femoral pulse weaker than radial pulse or absent. Alternating pulse (pulsus alternans), pulsus bisferiens, bigeminal pulse (pulsus bigeminus), bounding pulse, labile pulse, paradoxical pulse (pulsus paradoxus), pulsus differens, tachycardia, trigeminal pulse (pulsus trigeminus), or water-hammer pulse (Corrigan pulse).
Palpation of arterial pulses. A, Carotid. B, Brachial. C, Radial. D, Femoral. E, Popliteal. F, Dorsalis pedis. G, Posterior tibial.
• Rate	EXPECTED: 60-90 beats/min.
• Rate	UNEXPECTED: Rate different from that observed during cardiac examination.
• Rhythm	EXPECTED: Regular.
• Rhythm	UNEXPECTED: Irregular, either in a pattern or patternless.
• Contour	EXPECTED: Smooth, rounded, or dome-shaped.
A-F, Pulse abnormalities. (Modified from Barkauskas et al, 2002.)
• Amplitude	UNEXPECTED: Bounding, full, diminished, or absent. Describe on scale of 0-4: 0 = Absent, not palpable 1 = Diminished 2 = Expected 3 = Full, increased 4 = Bounding
Auscultate carotid and subclavian arteries; abdominal aorta; and renal, iliac, and femoral arteries for bruits
When auscultating the carotid vessels, you may at times need to ask patient to hold breath for a few heartbeats. Auscultate with bell of stethoscope.	UNEXPECTED: Transmitted murmurs, bruits.
Assess for arterial occlusion and insufficiency
• Site Assess for pain distal to possible occlusion.	UNEXPECTED: Dull ache accompanied by fatigue and often cramping; possible constant or excruciating pain. Weak, thready, or absent pulses; systolic bruits over arteries; loss of body warmth; localized pallor or cyanosis; delay in venous filling; or thin, atrophied skin, muscle atrophy, and loss of hair.
• Degree of occlusion Ask patient to lie supine. Elevate extremity, note degree of blanching, then ask patient to sit on edge of table or bed to lower extremity. Note time for maximal return of color when extremity is lowered.	EXPECTED: Slight pallor on elevation and return to full color as soon as leg becomes dependent.
	UNEXPECTED: Delay of >2 sec.
Measure blood pressure
Measure in both arms at least once. Patient’s arm should be slightly flexed and comfortably supported on table, pillow, or your hand.	EXPECTED: <120 mm Hg systolic and <80 mm Hg diastolic, with pulse pressure of 30-40 mm Hg (sometimes to 50 mm Hg). Reading between arms may vary by as much as 10 mm Hg. Prehypertension is now defined as a blood pressure between 120 and 139 mm Hg systolic or 80 and 89 mm Hg diastolic.
	UNEXPECTED: Hypertension (see Chapter 2).
Peripheral Veins
Assess jugular venous pressure
Ask patient to recline at 45-degree angle. With tangential light, observe the jugular vein. As shown in figure below, use a centimeter ruler to measure vertical distance between midaxillary line and highest level of jugular vein distention.	EXPECTED: Pressure ≤9 cm H₂O, bilaterally symmetric.
	UNEXPECTED: Abnormal elevation, distention or distention on one side.
Assess for venous obstruction and insufficiency
Inspect extremities, with patient both standing and supine.
• Affected area	UNEXPECTED: Constant pain with swelling and tenderness over muscles, engorgement of superficial veins, cyanosis.
• Thrombosis Flex patient’s knee slightly with one hand, and with other, dorsiflex foot to test for Homan sign.	UNEXPECTED: Redness, thickening, tenderness along superficial vein. Calf pain with test for Homan sign.
• Edema Press index finger over bony prominence of tibia or medial malleolus for several seconds.	UNEXPECTED: Orthostatic (pitting) edema; thickening and ulceration of skin possible.
	Grade edema from 1+ to 4+ as follows: 1+ = Slight pitting, no visible distortion, disappears rapidly 2+ = Deeper than 1+ and disappears in 10-15 sec 3+ = Noticeably deep and may last >1 min, with dependent extremity full and swollen 4+ = Very deep and lasts 2-5 min, with grossly distorted dependent extremity
• Varicose veins If suspected, have patient stand on toes 10 times in succession.	EXPECTED: Pressure from toe standing disappears in seconds.
	UNEXPECTED: Veins dilated and swollen; often tortuous when extremities are dependent and pressure does not quickly disappear.
• If varicose veins are present, assess venous incompetence with Trendelenburg test: Ask patient to lie supine, lift leg above heart level until veins empty, then quickly lower leg.	UNEXPECTED: Rapid filling of veins.
• Evaluate patency of deep veins with Perthes test: Ask patient to lie supine. Elevate extremity, and occlude subcutaneous veins with tourniquet just above knee. Then ask patient to walk.	UNEXPECTED: Superficial veins fail to empty.
• Evaluate direction of blood flow and presence of compensatory circulation: Put affected limb in dependent position, then empty or strip vein. Release pressure of one finger nearest heart to assess blood flow; if necessary, repeat and release pressure of other finger.	UNEXPECTED: Stripped vessel fills before pressure is released by distal finger, or blood refills entire vein when pressure is released by proximal finger.

Objective Data	Subjective Data
Arterial Aneurysm
Generally asymptomatic until they dissect or compress an adjacent structure. With dissection, the patient may describe a severe ripping pain.	Pulsatile swelling along the course of an artery. Occurs most commonly in the aorta, although renal, femoral, and popliteal arteries are also common sites. A thrill or bruit may be evident over the aneurysm.
Venous Thrombosis
Tenderness along the iliac vessels or the femoral canal, in the popliteal space, or over the deep calf veins. Deep vein thrombosis in the femoral and pelvic circulations may be asymptomatic. Pulmonary embolism may occur without warning.	Swelling may be distinguished only by measuring and comparing the circumference of the upper and lower legs bilaterally. There may be minimal ankle edema, low-grade fever, and tachycardia. Homan sign can be helpful but is not absolutely reliable in suggesting deep vein thrombosis.
Raynaud Phenomenon
Involved areas will feel cold and achy, which improves on rewarming. In secondary Raynaud phenomenon, there can be intense pain and digital ischemia with necrosis at the tips.	With primary Raynaud phenomenon, there is triphasic demarcated skin pallor (white), cyanosis (blue), and reperfusion (red) within the extremities. The vasospasm may last from minutes to less than an hour. In secondary Raynaud phenomenon, ulcers may appear on the tips of the digits, and eventually the skin over the digits can appear smooth, shiny, and tight from loss of subcutaneous tissue.

Technique	Findings
Palpate arterial pulses in distal extremities (see Chapter 2)
Auscultate arteries for bruits
	EXPECTED: In children, it is not unusual to hear a venous hum over internal jugular veins. There is usually no pathologic significance.
Measure blood pressure (see Chapter 2)

Subjective Data	Objective Data
Coarctation of the Aorta
Most patients are asymptomatic unless severe hypertension or vascular insufficiency develops. In those settings, patients may experience symptoms of heart failure or vascular insufficiency of an involved upper extremity with activity.	Differences in systolic blood pressure readings when the radial and femoral pulses are palpated simultaneously.

	C	B	R	F	P	PT	DP
L	2 +	2 +	2 +	2 +	2 +	2 +	2 +
R	2 +	2 +	2 +	2 +	2 +	2 +	2 +

Blood Vessels

Examination

Sample Documentation

Vessels

Extremities