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Home / Complete peripheral vascular examination
11-minute physical-examination master page

Complete peripheral vascular examination

Assess lower-limb perfusion systematically, distinguish arterial from venous disease, recognize acute limb ischemia and state urgent vascular escalation when a limb is threatened.

Candidate instructions

Lower-limb vascular examination

Your task

Perform a focused peripheral vascular examination on an adult with exertional calf pain and a new painful cool foot. At the end, summarize arterial and venous findings, state your differential, investigations and immediate management. You have 11 minutes.

Information available at entry
HR 92/minBP 146/86 mm HgRR 16/minSpO₂ 98%Temp 36.8°C
Safety priority: Acute limb ischemia is a vascular emergency. New severe pain with pallor, pulselessness, paresthesia, paralysis or a cold limb requires immediate vascular assessment; do not delay referral for a prolonged routine examination.

What examiners expect

  • Introduction, consent, hand hygiene and adequate bilateral exposure.
  • Inspection for colour, trophic change, ulcers, edema and venous disease.
  • Temperature and capillary-refill comparison.
  • Systematic palpation of femoral, popliteal, posterior tibial and dorsalis pedis pulses.
  • Recognition of acute limb-threat features.
  • Buerger positioning or ankle-brachial index when appropriate.
  • Focused venous assessment without using unreliable bedside tests to rule out DVT.
  • Clear investigation and vascular-referral plan.
Timed rehearsal

Run the complete station in 11 minutes

Perform the patient-facing examination efficiently, then reserve the final 90–120 seconds for synthesis, differential, investigations, management and safety.

Review procedureOpen practice library
Station time
11:00

Ready for an 11-minute attempt.

Complete procedure

Exact 11-minute examination sequence

Use the sequence as a flexible performance framework. Patient safety and the task on the door always take priority over completing every maneuver.

0:00–0:35

1. Immediate limb-threat screen

Say: “Before I continue, I would ask about sudden severe pain, numbness or weakness and look for a pale or cold limb.”
  • Assess the 6 Ps of acute limb ischemia conceptually.
  • Escalate immediately if motor/sensory loss or severe ischemia is present.
0:35–1:10

2. Introduce, identify, consent and expose

Say: “I need to examine the circulation in both legs from the groin to the feet. Is that okay?”
  • Hand hygiene.
  • Expose both legs while preserving dignity.
1:10–2:15

3. Inspect both legs and feet

Say: “I am looking for colour change, swelling, ulcers and skin changes.”
  • Pallor/cyanosis/rubor.
  • Hair loss, shiny skin, nail changes, muscle wasting.
  • Arterial ulcers versus venous gaiter changes.
  • Varicosities and edema.
2:15–3:00

4. Temperature and capillary refill

Say: “I will compare the temperature of both legs and check circulation in the toes.”
  • Use dorsum of hands to compare temperature.
  • Capillary refill in toes.
3:00–5:15

5. Palpate pulses systematically

Say: “I will feel the pulses in both legs and compare them.”
  • Femoral pulses.
  • Popliteal pulses.
  • Posterior tibial pulses.
  • Dorsalis pedis pulses.
  • Assess pulse character and asymmetry.
  • Consider abdominal aortic palpation when relevant.
5:15–6:10

6. Auscultation and arterial bedside tests if indicated

Say: “If I detect a reduced femoral pulse, I would listen for a bruit and measure an ankle-brachial index.”
  • Femoral bruit if indicated.
  • ABI/Doppler rather than subjective pulse exam alone for PAD assessment.
6:10–7:00

7. Buerger positioning when chronic arterial disease suspected

Say: “If appropriate and safe, I would elevate then lower the leg to look for pallor and dependent rubor.”
  • Use selectively; avoid delaying care in acute ischemia.
7:00–8:00

8. Focused venous examination

Say: “I will look for swelling, skin changes and tenderness suggestive of venous disease.”
  • Measure/compare calf swelling if DVT suspected.
  • Inspect varicosities, edema, hemosiderin and venous ulcers.
  • Do not use Homan sign to exclude DVT.
8:00–8:45

9. Neurologic/function screen

Say: “I would check sensation and movement in the foot because loss of either can indicate threatened limb viability.”
  • Light-touch sensation.
  • Ankle/toe movement.
  • Functional walking only if safe.
8:45–9:15

10. Completion

Say: “Thank you. I will help you get comfortable and clean my hands.”
  • Cover patient.
  • Reassess pain/perfusion if abnormal.
9:15–11:00

11. Present and prioritize

Say: “There are signs of reduced arterial perfusion in the affected limb. If this is acute, I would treat it as acute limb ischemia and obtain immediate vascular input.”
  • ABI for stable PAD.
  • Urgent arterial Doppler/CTA according to vascular pathway in acute ischemia.
  • Risk-factor management for chronic PAD.
  • Immediate vascular surgery consultation for threatened limb.
Interpretation

High-yield finding patterns

Finding patternClinical interpretation
Cool pale pulseless painful limbAcute limb ischemia — emergency
Reduced pulses + claudication + trophic changesPeripheral arterial disease
Dependent rubor/elevation pallorAdvanced arterial insufficiency
Edema + hemosiderin + gaiter ulcersChronic venous insufficiency
Unilateral swelling/tendernessPossible DVT; requires validated clinical pathway and imaging
Clinical reasoning

Prioritized differential

  1. Peripheral arterial disease
  2. Acute limb ischemia from embolus/thrombosis
  3. Deep-vein thrombosis
  4. Chronic venous insufficiency
  5. Neuropathic/diabetic foot disease
  6. Musculoskeletal or neurogenic claudication

Presentation formula

Start with stability, then the key positive and negative findings, localization or syndrome, leading diagnosis, and the most dangerous alternative that must be excluded.

Avoid: a long unranked list. Explain which finding makes each top diagnosis more or less likely.
Targeted tests

Investigations

Ankle-brachial index for stable suspected PAD

Handheld Doppler pulse assessment when pulses are difficult to palpate

Duplex ultrasound for venous disease/DVT pathway and selected arterial evaluation

CTA/MRA or urgent vascular imaging for suspected acute limb ischemia according to local protocol

ECG and embolic-source work-up when acute embolism is suspected

Immediate plan

Management and disposition

  1. Acute threatened limb: immediate vascular consultation and emergency pathway; analgesia, IV access and anticoagulation when appropriate under protocol.
  2. Stable PAD: smoking cessation, exercise therapy, antiplatelet/statin and cardiovascular risk-factor management when indicated.
  3. Foot care and ulcer/wound management.
  4. DVT suspicion: use validated pretest probability and diagnostic pathway rather than bedside signs alone.
  5. Escalate any rest pain, tissue loss or neurologic deficit promptly.

Safety-netting

State exactly what would trigger urgent reassessment, specialist escalation, monitored care or admission. Do not hide emergency actions inside a generic “follow up” statement.

  • Screens for acute limb ischemia
  • Compares both limbs
  • Checks femoral to pedal pulses
  • Assesses motor and sensory function
  • Avoids Homan sign as a rule-out test
  • Uses ABI/Doppler appropriately
Self-assessment

Critical-action checklist

Use this after a timed attempt. These actions carry disproportionate safety value.

0 / 8 completed
0 / 8 critical actions completed
Evidence and next practice

References and linked learning

Reference starting points

Educational preparation only. Patient care must follow current patient-specific assessment, local policy and current guidelines.

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