peri

• The Peripheral Vascular System

  • An extensive vascular network that drains lymph fluid from body tissues and returns it to the venous circulation
  • Lymph nodes are round, oval, or bean-shaped structures that vary in size according to their location
• Common or Concerning Symptoms

  • Pain in the arms or legs
  • Intermittent claudication
  • Cold, numbness, pallor in the legs; hair loss
  • Swelling in calves, legs, or feet
  • Color change in fingertips or toes in cold weather
  • Swelling with redness or tenderness
• Important Areas of Examination

  • The Arms: Size, symmetry, skin color; Radial pulse, brachial pulse; Epitrochlear lymph nodes
  • The Legs: Size, symmetry, skin color; Femoral pulse and inguinal lymph nodes; Popliteal, dorsalis pedis, and posterior tibial pulses; Peripheral edema
• Key Components of the Peripheral Arterial Examination

  1. Measure blood pressure in both arms

  2. Palpate carotid upstroke, auscultate for bruits

  3. Auscultate for aortic, renal, and femoral bruits; palpate aorta and determine maximal diameter

  4. Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior arteries

  5. Inspect ankles and feet for color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin changes, hypertrophic nails
• Grading of Pulses


  • 3+ Bounding
  • 2+ Brisk, expected (normal)
  • 1+ Diminished, weaker than expected
  • 0 Absent, unable to palpate
• Inspect the Arms


  1. Note their size, symmetry, and any swelling

  2. Note the venous pattern

  3. Note the color of the skin and nail beds and the texture of the skin

  4. Lymphedema of the arm and hand may follow axillary node dissection and radiation therapy

  5. Prominent veins in an edematous arm suggest venous obstruction
• Inspect the Legs


  1. Note their size, symmetry, and any swelling

  2. Note the venous pattern and any venous enlargement

  3. Note any pigmentation, rashes, scars, or ulcers

  4. Note the color and texture of the skin, the color of the nail beds, and the distribution of hair on the lower legs, feet, and toes
• Palpate the Superficial Inguinal Nodes

  1. Note their size, consistency, and discreteness, and note any tenderness

  2. Nontender, discrete inguinal nodes up to 1 cm or even 2 cm in diameter are frequently palpable in normal people

  3. Lymphadenopathy refers to enlargement of the nodes, with or without tenderness
• Lymphadenopathy can be local or generalized
• Check for Temperature Abnormalities


  1. Note the temperature of the feet and legs with the backs of your fingers. Compare one side with the other

  2. Bilateral coldness is most often caused by a cold environment or anxiety

  3. Coldness, especially when unilateral or associated with other signs, suggests arterial insufficiency from inadequate arterial circulation
• Check for Edema


  1. Compare one foot and leg with the other, noting their relative size and the prominence of veins, tendons, and bones

  2. Edema causes swelling that may obscure the veins, tendons, and bony prominences
• Check for Pitting Edema


  1. Press firmly but gently with your thumb for at least 5 seconds (1) over the dorsum of each foot, (2) behind each medial malleolus, and (3) over the shins

  2. Look for pitting—a depression caused by pressure from your thumb

  3. Normally there is none. The severity of edema is graded on a four-point scale, from slight to very marked
• Grade 3 Pitting Edema
• Recording the Physical Examination

  • Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric.
  • Extremities are pale below the midcalf, with notable hair loss. Rubor noted when legs dependent but no edema or ulceration. Bilateral femoral bruits; no abdominal bruits heard. Brachial and radial pulses 2+; femoral, popliteal, DP and PT pulses 1+.