Misc Flashcards
Vascular inspection upper limb
Peripheral cyanosis: bluish discolouration of the skin associated with low SpO2 in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).
Peripheral pallor: a pale colour of the skin that can suggest poor perfusion (e.g. PVD).
Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. PVD, coronary artery disease, hypertension).
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.
Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.
Pulses in upper limb vascular
Radial (radio-radial delay)
Brachial
Carotid
AAA
Causes of radio-radial delay
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
BP abnormalities
Wide pulse pressure (more than 100 mmHg of difference between systolic and diastolic blood pressure) can be associated with aortic regurgitation and aortic dissection.
A more than 20 mmHg difference in BP between arms is abnormal and is associated with aortic dissection.
Upper limb vasc auscultation
Aortic bruits
Renal bruits
Carotid bruits
Vascular inspection lower limb
Peripheral cyanosis: bluish discolouration of the skin associated with low SpO2 in the affected tissues (e.g. may be present in the peripheries in PVD due to poor perfusion).
Peripheral pallor: a pale colour of the skin that can suggest poor perfusion.
Ischaemic rubour: a dusky-red discolouration of the leg that typically develops when the limb is dependent. Ischaemic rubour occurs due to the loss of capillary tone associated with PVD.
Venous ulcers: typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle.
Arterial ulcers: typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).
Gangrene: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red, black) and breakdown of the associated tissue.
Missing limbs, toes, fingers: due to amputation secondary to critical ischaemia.
Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.
Hair loss: associated with PVD due to chronic impairment of tissue perfusion.
Muscle wasting: associated with chronic peripheral vascular disease.
Xanthomata: raised yellow cholesterol-rich deposits that may be present over the knee or ankle. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease.
Paralysis: critical limb ischaemia can cause weakness and paralysis of a limb. To perform a quick gross motor assessment, ask the patient to wiggle their toes.
Lower limb vascular pulses
Femoral pulse (radio-femoral delay)
Popliteal pulse
Posterior tibial pulse
Dorsalis pedis pulse
Buerger’s test
used to assess adequacy of arterial supply to leg
- With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.
- Observe the colour of the limbs:
The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known as Buerger’s angle.
In a healthy individual, the entire leg should remain pink, even at an angle of 90º.
A Buerger’s angle of less than 20º indicates severe limb ischaemia.
3. Sit the patient up and ask them to hang their legs down over the side of the bed:
Gravity should now aid reperfusion of the leg, resulting in the return of colour to the patient’s limb.
The leg will initially turn a bluish colour due to the passage of deoxygenated blood through the ischaemic tissue. Then the leg will become red due to reactive hyperaemia secondary to post-hypoxic arteriolar dilatation (driven by anaerobic metabolic waste products).
To complete vascular exam
Blood pressure measurement: to identify significant discrepancies between the two arms suggestive of aortic dissection.
Cardiovascular examination: to complete assessment of the vascular system.
Ankle-brachial pressure index (ABPI) measurement: to further assess lower limb perfusion.
Upper and lower limb neurological examination: if gross neurological deficits were noted during the peripheral vascular examination.
Breast inspection
Scars: these may indicate previous breast surgery such as lumpectomy (small scar) or mastectomy (large diagonal scar).
Asymmetry: this can be helpful in identifying abnormalities via comparison, however, it should be noted that breast asymmetry is a normal feature in most women.
Masses: note any visible lumps that will require further assessment.
Nipple abnormalities: these can include nipple inversion and discharge.
Skin changes: including scaling, erythema, puckering and peau d’orange.
Nipple abnormalities
Nipple inversion is a normal finding in a significant proportion of women (e.g. congenital or weight-loss associated nipple inversion). However, if nipple inversion develops without a clear precipitant, the possibility of underlying pathology should be considered. Possible pathological causes of nipple inversion include breast cancer, breast abscess, mammary duct ectasia and mastitis.
Nipple discharge is benign is most cases (e.g. pregnancy, breast-feeding) however less commonly it can be associated with mastitis or underlying breast cancer (rare).
Skin changes in breast pathology
Scaling of the nipple and/or areola associated with erythema and pruritis are typical features of Paget’s disease of the breast (see the example image). Paget’s disease is associated with underlying in-situ or invasive carcinoma of the breast.
Erythema of the breast tissue has a wide range of causes including infection (e.g. mastitis or breast abscess), trauma (e.g. fat necrosis) and underlying breast cancer.
Puckering of breast tissue is typically associated with invasion of the suspensory ligaments of the breast by an underlying malignancy that results in ligamentous contraction which draws the skin inwards.
Peau d’orange (dimpling of the skin resembling an orange peel) occurs due to cutaenous lymphatic oedema. The dimples represent tethering of the swollen skin to hair follicles and sweat glands. Peau d’orange is typically associated with inflammatory breast cancer.
Nipple discharge causes
Milky discharge: normal during pregnancy and when breastfeeding (bilateral). Galactorrhoea (nonpuerperal lactation) is pathological and caused by the presence of a prolactinoma.
Purulent discharge: thick yellow, green or brown discharge with an offensive smell. Possible causes include mastitis and central breast abscess.
Watery and bloody discharge: several possible causes however ductal carcinoma in situ is the most important diagnosis to consider.
Lymph nodes in breast exam
Axillary
Supraclavicular
(optional: cervical, infraclavicular, parasternal)
