# 52 Ultrasound Unlocked

How to Obtain and Perform the Vascular Physical Exam – And Why It Matters

If your first move with every vascular patient is “order a duplex,” you’re not alone - but

you might be skipping the most valuable test you have. A focused vascular history and

physical exam can narrow the differential, localize disease, and often expose pathology

that never showed up in the chief complaint. In this post, we’ll break down a

step‑by‑step vascular examination checklist - from inter‑arm blood pressure differences

and pulse grading to venous skin changes and bedside maneuvers - so your imaging

becomes targeted confirmation, not an expensive fishing expedition.

In a typical clinic day, it is easy for the vascular physical exam to become a formality -

quick pulses, a glance at the legs, and then straight to imaging. Yet time after time,

careful bedside assessment has changed how a case is framed before the patient ever

reaches the lab. When we slow down and perform a structured vascular exam, we often

pick up details that imaging alone would never fully explain.

Why the Vascular Exam Is Still Worth the Time

Several realities compete with the exam: tight schedules, EMR demands, instant access

to duplex and cross‑sectional imaging, and patient expectations that equate “good care”

with high‑tech testing. Against that backdrop, dedicating a few extra minutes to a

focused vascular exam can feel like a luxury.

In practice, it is the opposite:

• It gives immediate, bedside answers about which limb segment and which vascular

bed truly need attention.

• It helps you order the right test instead of “all the tests.”

• It shows patients that you are actually examining them—not just interacting with a

computer and a scanner.

How to Structure the Exam

A simple way to keep the exam efficient and reproducible is to think in zones: vitals and

general inspection, head and neck, upper extremities, abdomen, and lower extremities.

• Vitals and first impressions

• Always measure blood pressure in both arms; consistent differences are a clue, not an

annoyance.

• In a warm environment, with proper exposure, scan for global markers of vascular

disease—skin changes, lipid deposits, telangiectasias, tobacco stains, and asymmetric

limb size or color.

Head and neck

• Palpate temporal arteries, examine the retinae, and listen in the neck with a clear

plan for distinguishing local vascular disease from transmitted cardiac murmurs.

Upper extremities

• Look for venous congestion patterns and acral changes.

• Check subclavian and axillary pulses and pressures; combine arm symptoms with

neurologic complaints to decide when to suspect subclavian disease or steal.

• Use the Allen and digital Allen tests when assessing hand perfusion or planning radial

access.

Abdomen

• Look, listen, then feel: inspect for scars and collaterals, auscultate for bruits, and then

palpate the aorta to estimate size and tenderness.

Lower extremities

• Distinguish arterial, venous, and neuropathic ulcers by location and surrounding skin

changes.

• Recognize varicose patterns, chronic venous skin changes, and lymphedema

phenotypes that influence how you investigate and counsel the patient.

• Palpate all key pulses, using thoughtful positioning and alternate techniques when

access is challenging.

Along the way, simple maneuvers like leg elevation and dependency, venous filling time,

and a bedside ABI add physiologic context that pure imaging cannot.

Making It Part of Your Routine

The easiest way to make this “stick” is to standardize it:

• Use the same sequence on every patient so it becomes second nature.

• Document findings in a structured way that you can quickly review over time.

• Link specific exam findings to specific imaging choices in your own mental algorithm.

A structured vascular history and physical exam is still the best “first test” you have. It

sharpens your differential, targets your duplex and cross‑sectional imaging and often

picks up pathology that never made it into the chief complaint. The real question isn’t

whether you can order more tests - it’s whether your bedside exam is good enough to

tell you which one’s matter!

“Portions of this discussion are inspired by John R. Bartholomew’s 2021 ‘From the

Masters’ article on the vascular history and physical examination in Vascular Medicine.”