Examination Flashcards
Arterial - general inspection
Look around the bed for a false leg, inhalers for asthma or diabetes medication.
For signs of arterial disease e.g. previous amputations, ulcers, gangrenous toes, peripheral cyanosis or abnormal pulsations e.g. on the abdomen suggesting an AAA.
Arterial - the hands
Inspect the hands for tobacco staining, amputations, splinter haemorrhages, purple discolouration of the finger tips (athero-embolism), pits and healed scars in the finger pulps (secondary Raynaud’s) or wasting of the small muscles of the hand (in thoracic outlet syndrome – compression of vessels and nerves between ribs and the clavicle leads to symptoms in the arms).
Examine the radial and brachial pulses, check for radio-radial delay (found in co-arctation and dissection) and measure the blood pressure in both arms (there should not be >15 mmHg difference between the arms unless there is a vascular problem).
Arterial - the face and neck
Inspect for corneal arcus and xanthelasma (hypercholesterolaemia), Horner’s syndrome (in carotid artery dissection or aneurysm), hoarseness of the voice or a bovine cough (recurrent laryngeal nerve palsy from a thoracic aortic aneurysm) or prominent veins in the neck, shoulder and anterior chest (due to axillary or subclavian vein occlusion).
Palpate the carotid pulse and auscultate for a bruit using the diaphragm of the stethoscope (ask the patient to hold their breath on expiration) and palpate the subclavian pulse (just above the clavicles).
Arterial - the abdomen
Inspect for scars, obvious epigastric or umbilical pulsations (aorto-iliac aneurysm), mottling of the abdomen (ruptured AAA or saddle embolism) or evidence of weight loss (in visceral ischaemia).
Palpate over the abdominal aorta (above the umbilicus) – if the aorta is easily palpable (expansible or pulsatile) consider the possibility of an AAA – if in doubt arrange a duplex ultrasound scan.
Auscultate for aortic and renal bruits.
Arterial - legs inspection
Inspect the legs and feet for changes of ischaemia – temperature, colour changes e.g. pallor or cyanosis, areas of necrosis or onicholysis. Note scars from previous vascular or non-vascular surgery and the position, margin, depth and colour of any ulceration. Look between the toes and at the heels for ischaemic changes. Also compare the capillary refill times of each big toe.
Arterial - leg palpation
- Femoral pulse – patient lies flat, explain what you are going to do, use pads of your index and middle fingers, check for radio-femoral and femoral-femoral delay and listen for bruits.
- Popliteal pulse – flex knee to 30°, put your thumbs in front of the knee and your fingers behind (between the 2 heads of gastrocnemius at the distal end of the femur), press firmly in the midline to feel the pulse. If it is very easy to feel consider a popliteal aneurysm.
- Posterior tibial pulse – feel 2 cm below and 2cm behind the medial malleolus.
- Dorsalis pedis pulse – feel the dorsum of the foot between the extensor tendons of the big toe and second toe (this is absent in 10% of patients whichis a normal variant).
Buerger’s angle
The angle to which the leg must be raised before it becomes white - >90° is normal, between 20-30° demonstrates an ischaemic leg and <20° suggests severe ischaemia.
Venous guttering
Raise the leg and if ischaemia is present the veins will be collapsed. In a normal foot the veins will empty but will not gutter. It can occur at 10-15° if severe ischaemia.
Buerger’s test
With the patient supine stand at the foot of the bed and raise the patients feet and support the legs at 45° for 2-3 minutes. The rate at which the skin blanches should be observed – differences between the 2 sides are more useful than any absolute change.
- Then ask the patient to sit up with their legs over the edge of the bed and watch the patient’s feet for another 2-3 minutes. Look at the rate at which the veins in the foot refill and the rate at which colour returns to the legs – again comparing the two legs is more useful.
- Pallor on elevation (with emptying or ‘guttering’ of the superficial veins) followed by reactive hyperaemia (rubor) on dependency = a positive test and indicates critical ischaemia.
- Reactive hyperaemia is due to vasodilation caused by accumulation of products of anearobic metabolism during the period of elevation (due to poor vascular supply).
Examination - anything else
Cardiovascular and neurological examinations and ankle brachial pressure index in both legs.
- ABPI - 0.8-1 is normal, 0.6-0.8 is claudication and <0.6 is critical ischaemia. The value may be falsely high in diabetics and renal failure due to calcification of vessels (they can’t be compressed).
What to Say at the End - Upper Limb
The patient appears comfortable at rest, there are no peripheral stigmata of chronic disease. His fingers are nicotine stained.
He is not tachycardic, the rhythm is regular and there is no radio-radial delay.
You have indicated that he is normotensive.
There is full complement of supra-aortic pulses and no bruits.
I always perform a full examination or the praecordium in my normal practice.
What to Say at the End - Lower Limb
On inspection of the legs there are no obvious scars or ulceration.
There is no difference in temperature between the 2 limbs.
The patient had billateral and equal femoral pulses with no radio-femoral delay.
There were palpable popliteal pulses and a full complement of pedal pulses.
I detected no bruits on auscultation.
Buerger’s test was negative.
I would like to perform ABPIs on both sides.
Venous - Inspect the Legs
With the patient standing – for oedema, skin pigmentation (brown due to deposits of haemosiderin), lipodermatosclerosis (atrophy and loss of elasticity of the skin and subcutaneous tissue), superficial venous dilation and tortuosity (dilations of the long saphenous vein are found on the medial aspect of the thigh and calf whereas dilations of the short saphenous vein are found on the lateral aspect of the calf), scars from previous healed ulcers or surgery and ulceration.
Venous - palpate the legs
Patients with a prominent saphena varix at the saphenofemoral junction may produce a visible lump in the groin and this should be palpated to make sure it’s not a lymph node or hernia.
- Compare each leg for differences in temperature and for pitting oedema and assess how far up the leg it occurs. If oedema is found check the JVP – raised in heart failure or pulmonary hypertension.
- Tap test – tap down the calf and feel for a palpable thrill over the saphenofemoral junction.
Tredelenburg Test
Used to detect the position of the defect e.g. saphenofemoral or saphenopopliteal junction regurgitation – ask the patient to lie on the bed, raise the leg as far as comfortable and empty the superficial veins by ‘milking’ the leg. With the patients leg still elevated press with thumb over the saphenofemoral junction or use a high thigh tourniquet.
- Ask the patient to stand whilst you maintain pressure over the junction – look for rapid filling of the varicose veins (veins filling slowly is a normal process). If regurgitation is present at the saphenofemoral junction the patient’s varicose veins will not fill until pressure or tourniquet is removed. However if regurgitation is present at the saphenopopliteal junction or perforator veins varicose veins will fill rapidly even with the high thigh tourniquet in place.
- This test can be repeated by placing the tourniquet just below the knee – if the veins are now prevented from filling there is saphenopopliteal reflux (or rarely an incompetent thigh perforator).
