PVS

Question 1

1. Introduction

Answer 1

1. Wash hands
2. Introduce myself to patient - full name, role, PA student
3. Confirm patient full name/D.O.B/ age
4. Confirm confidentiality
5. Explain encounter- PVS exam - involve me looking at your hands, face, feeling pulses in arms/legs
6. Gain consent
7. Remove your tshirt pls, look at you from end of bed
8. 45 degree patient position
9. Any pain?

Question 2

2. General inspection

Answer 2

1. Is patient comfortable?
2. Any obvious scars? Bypass surgery or vein harvest sites
3. Any medical equipment ? 02, cardiac monitor, medications
4. Lower limbs- varicose veins, venous stasis changes, oedema, hair loss/muscle wasting (PVD),
5. Colour of feet
6. Ulcers / gangrene (necrosis secondary to inadequate limb perfusion) lift leg up one by one
7. Pallor (poor vascular perfusion) or cyanosis
8. Inspect toes one by one for ulcers
9. Wiggle toes- gross motor movement (paralysis due to ischaemia)
10. Eczema

Question 3

3. Auscultation

Answer 3

1. Bruits with bell
2. Carotid
3. Aortic - aorta bruit using diaphragm -> suggestive of aortic aneurysm.
4. Renal
5. Iliac
6. Femoral - diaphragm femoral/iliac stenosis)

Question 4

4. Palpatation

Answer 4

1. Feel for temperature in all limbs - simultaneous and bilateral. Hands arms/ankle legs (if temp decreases = poor peripheral perfusion) (3 points)
2. Check capillary refill (<2 secs) and big toe
3. Check for pitting oedema (thumbs on ankle)
4. Presence, symmetry, rate, rhythm, volume, character of pulses:
5. Carotids one by one (bruits -> stenosis)
6. Brachial (simultaneously)
7. Radial (radial radial delay - aortic coarctation)
8. Femoral (pulses in groin assess radial-femoral delay) (coarctation of aorta)
9. Popliteal bend knees slightly (diaphragm auscultation bruit = stenosis / aneurysm )
10. Posterior tibialis
11. Dorsalis pedis
12. Bed down flat. Checks abdominal aorta at epigastric area for pulsation masses (aneurysm). Palpate either side- expansion of aneurysm

Question 5

5. Conclusion

Answer 5

Sensation- right left right left (acute limb ischaemia indicator)

1. State if time permitted would do blood pressure - sig difference = aortic anaeurysm) ABPI
2. Thank patient

Summarise- today I performed a peripheral vascular examination on X the exam was unremarkable and no stigmata of PVD

3. Wash hands
4. Leave and dress

Question 6

6. Special tests if suspicion of critical ischaemia

Answer 6

1. Modified Allen’s test
   - ask patient clench fist 40 secs
   - release fist
   - circulatory defect if >6 secs to go back to original colour
2. Buerger’s test
   - patient supine lift bilateral legs to 45 degrees
   - hold 2 mins
   - observe if pallor
   - return seated legs over bed
   - peripheral artery disease when legs go from pale to pink/ blue-red
3. ABPI (ankle brachial pressure index)
   - Doppler US device- measure systolic pressure at brachial artery and posterior tibilias artery
   - divide posterior tibialis/ brachial BP
   - ABPI >1 normal