Using Point of Care Ultrasound to Augment Acquisition of Physical Exam Skills: Veins and Arteries

1. Examination of Arteries: The Dorsalis Pedis Pulse

1. Review the examination of peripheral arteries here: JoVE Video 10122: Peripheral Vascular Exam.
2. Select the linear probe and the vascular preset on the ultrasound machine.
3. Use the ultrasound to examine the artery of interest in transverse view and identify surrounding structures that act as landmarks for the physical exam. These may include tendons, bony landmarks, or other vessels. Landmarks are reviewed in the Jove video on the peripheral vascular exam.
4. The artery should be pulsatile and not fully compressed when pressure is applied to the ultrasound probe.
5. Mark the vessel using a skin marking pen.
6. Identify surface landmarks by inspection and palpation, then use the finger pads to palpate the artery.
7. This process can be used to guide palpation of all arteries relevant to the physical exam, including the brachial, radial, ulnar, femoral, popliteal, posterior tibialis, dorsalis pedis, carotid, and abdominal aorta.

2. Examination of the Internal Jugular (IJ) Vein 

1. Review the examination of the IJ vein here: JoVE Video 10071— Cardiac Exam I: Inspection and Palpation
2. Select the linear probe and the vascular preset on the ultrasound machine.
3. Have the patient lie supine at 30° of incline.
4. Use the ultrasound to examine the IJ vein in transverse view and identify surrounding structures that act as landmarks for the physical exam. These include the sternocleidomastoid muscle and the carotid artery.
5. With the IJ and carotid in view, note the difference in pulsatility. The carotid has a single pulse, while the IJ has a triple pulse corresponding to the a, c, and v waves.
6. Have the patient Valsalva and notice the increase in the caliber of the IJ.
7. Have the patient take a deep inhalation and notice the IJ collapse. Correlate this with the increased blood return to the right side of the heart with inhalation, which leads to the physiologic splitting of the second heart sound.
8. Rotate the probe 90° with the indicator directed towards the patient's head to obtain the long axis of the IJ.
9. Identify the point where the IJ tapers and mark that spot with the skin marking pen.  Measure the height of the mark above the sternal angle. This correlates with the height of the jugular venous pressure (JVP) on the physical exam.
10. Using inspection, identify the IJ and height of the JVP. Compare your visual inspection with the JVP obtained using ultrasound.

3. Examination of the Abdominal Aorta

1. Review the palpation of the abdominal aorta here: JoVE Video 10122: Peripheral Vascular Exam.
2. Have the patient in the supine position.
3. Palpate the abdominal aorta and mark the lateral walls with a skin marking pen.
4. Measure the width of the abdominal aorta.
5. Select the curvilinear probe and the abdominal preset on the ultrasound machine.
6. With the probe indicator directed towards the patient's right, use the ultrasound to identify and optimize the abdominal aorta in the same area in which the aorta was palpated.
7. Freeze your image and measure the diameter of the aorta between the outer walls.
8. Compare the measurement of the width of the abdominal aorta by palpation and by ultrasound.