Breast and Vascular examination Flashcards by Ciaran O'Toole

What do you inspect in the hands during the vascular exam

colour
cigarette tar staining
tendon xanthomata
scars

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what do you palpate in the arm in the vascular exam?

temperature of hands
cap refill
radial pulse (rate, rhythm)
radio-radial delay
ask for BPs

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what do you palpate/auscultate in the neck in the vascular exam?

carotid for pulse + bruits

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what do you inspect for in the abdominal part of a vascular examination?

done at the level of the patient

inspect for scars e.g. midline laparotomy or T-shaped scar

inspect for pulsatile aorta (above level of the umbilicus)

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what scar suggests emergency AAA repair?

T shaped scar

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What do you palpate/auscultate for in the abdominal part of a vascular examination

aorta (above umbilicus)
auscultate aortic bruit / renal bruit

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what do you inspect in the lower limb aspect of the vascular examination?

colour
skin: shiny or hairless
scars
ulcers

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what would be indicated by a long saphenous vein scar?

vein harvesting for CABG

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where do you need inspect specifically in the feet when doing a lower limb exam?

Check number of toes (has there been any amputations?)
check on sole of foot / tips of toes and between toes for arterial ulcer

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what do you palpate for in a lower limb vascular examination?

temperature
gross sensation
cap refill
pulses

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how do you locate the femoral pulse?

mid-inguinal point, halfway between ASIS and pubic symphysis

Ask the patient to lower their shorts ever slightly

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what pulses do you need to feel for in lower leg part of vascular?

femoral (+ check for bruit)
popliteal
dorsalis pedis
anterior tibial

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how do you locate the dorsalis pedis pulse?

lateral to tendon of extensor hallucis longus (absent in 10% of people)

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how do you locate the posterior tibial pulse?

2cm below and behind medial malleolus

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what further examinations should you say you’d do to complete a vascular examination?

full cardiovascular examination

neurological and venous examination of the upper and lower limb

special test: perform Buerger’s test if indicated

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what is the first part of buerger’s test?

elevate both legs to 45 degrees and observe the colour

pallor = ischemia

the poorer the arterial supply, the less the angle that is needed to elevate the legs for them to become pale (Buerger’s angle)

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what is the second part of Buerger’s test?

sit the patient up and ask them to hang their legs down the side of the bed at 90 degrees

observe the colour changes as blood returns to the limb

blue initially (as blood is deoxygenated in its package through ischaemic tissue)

later will be red (reactive hyperaemia from post-hypoxic vasodilation)

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what bedside investigations should you mention after finishing a vascular examination?

ankle-brachial pressure index
measure claudication distance and total walking distance
12 lead ECG
capillary glucose
fundoscopy (for hypertensive and diabetic retinopathy)

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what further investigations can you mention for a vascular exam?

bloods (FBC, U+Es, lipids, ESR/CRP, glucose and HbA1c)
Arterial duplex
Angiography

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what angle in Buerger’s test indicates severe peripheral arterial disease?

20 degrees

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how do you interpret an ABPI result

> 1.3 = calcified vessels (e.g. diabetes)
0.9-1.2 = normal
0.8-0.9 = mild peripheral arterial disease
0.5-0.8 = moderate
<0.5 = critical limb ischaemia

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at what ABPI are compression bandages contraindicated?

below 0.8

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list some risk factors for peripheral arterial disease

diabetes
HTN
hyperlipidaemia
family history
tobacco smoking

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what are the features of an acutely ischaemic limb (in chronological order)

pain
pallor
pulseless
perishingly cold
paraesthesia
paralysis

classify the causes of acute limb ischaemia

thrombosis (70%) emboli (25%) -> AF / aneurysm

what is the timeframe for salvaging an acutely ischaemiac limb

6 hours or less after this window, the limb viability drops off rapidly

what are the management options for acute limb ischaemia?

thrombotic cause -> urgent CT angiography plus balloon angioplasty/open surgery embolic cause: -> catheter directed thrombolysis -> surgical arterial embolectomy -> both of them followed with LMWH

what are the possible reperfusion injuries that can occur as a result of revascularising an acutely ischemiac limb?

compartment syndrome rhabdomyolysis (AKI / hyperkalaemia) ARDS

what is intermittent claudication?

Cramping calf/thigh/ buttock pain felt after walking for a given distance (the claudication distance) and relieved by rest

what is suggested by calf claudication in peripheral arterial disease?

femoral disease

what is suggested by buttock pain in peripheral arterial disease?

iliac disease

definition of critical limb ischaemia

Pain at rest associated with the requirement for strong analgesia for at least 2 weeks/ tissue necrosis or gangrene + ABPI <0.5

symptoms of critical limb ischaemia

burning pain at rest nocturnal pain that wakes patient from sleep pain may be relieved by hanging limb over side of bed / walking on cold floor

how do you manage a patient with critical limb ischaemia?

ABC approach Analgesia Refer to MDT Urgent CT angiography for treatment planning

What are the things you need to cover in the intro for a breast examination

Wash hands Introduce yourself Confirm patient details Explain examination: ‘this will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally, I will examine the glands of your neck and armpit’ Gain consent CHAPERONE (most important) Ask about pain

What phrase can you use to explain a breast examination?

This examination will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally I will examine the glands of your neck and armpit.

Outline the basic steps in a breast examination

Inspect: multiple positions Palpate breast then axilla

What position should you ask the patient to take in a breast examination?

Undressed to waist (behind curtain) Once they are ready, ask them to sit upright on side of the bed, hands relaxed by side

What things are you looking for on inspection of the breasts?

Asymmetry Swelling Obvious masses Skin and nipple changes

What are the two main different types of scars in a breast examination?

Small = lumpectomy Large = mastectomy

If you see any masses on a breast examination, what specific characteristics should you look at?

Position Size and shape Consistency Mobility Fluctuancy Skin changes

What things are looking for on inspection of the skin in a breast examination?

Erythema Puckering (indrawing) Peau d’orange

What may erythema of breast skin indicate?

Infection / superficial malignancy

What may puckering indicate on breast exam?

?underlying malignancy

What may peau d’orange indicate on a breast examination?

Inflammatory breast cancer

What areas do you inspect in a breast examination?

Breast tissue itself Skin Nipple Axilla Check for radiology tattoos

What are the three separate positions you need to do inspection in a breast exam in?

1 (starting position) -> sit upright on side of bed, hands relaxed by side 2 -> hands on hips and push in 3 -> slowly raise hands behind head

During inspection part of breast examination, what should you do if patient has large breasts

Remember to inspect underneath, ask patient to move themselves

What position should you ask the patient to take when palpating in a breast exam

45 degree angle on bed Patient places one hand behind head -> examine this side then swap hands and breast Use flats of your right hand, place your left hand on shoulder

What are the key bits to remember when doing palpating of the breast in a breast examination

Use flats of fingers Compress tissue against chest wall Cover all areas including nipple (systematic approach in grid method) Palpate the upper outer quadrant last, and move up the ancillary tail to the armpit, then do axilla palpation

What comes after you have palpated both breasts in a breast examination?

Examination of the axilla

How do you examine a patients axilla in breast exam

Use your right arm to support the patients right arm (examine the same side) Cover all areas of the axilla, up into the apex Press fairly firmly

Phrase to use when moving to palpation of breast tissue

‘I’m going to examine your breasts now’

Two things to ask before doing palpation of breast tissue

Do you have any pain? Do you have anything that you’ve felt in your breasts?

What comes after examining axilla in breast exam?

Supraclavicular fossa lymph node palpation

What does a central venous catheter for dialysis look like?

Tesio line: 2 tunnelled cuffed lines into chest

What are the two types of AV fistulas in the arm

Above elbow: brachiocephalic fistula Wrist and above: Radiocephalic fistula

What are some basic things to look out for with a fistula in PACES

If buzzing, it’s normally a healthy one If it’s pulsating, not a good sign If you lift the arm above the head and the fistula collapses, that is a good sign