Wash Hands Introduce yourself, explain & gain consent Check patient ID Is the exam general or focused?
2. General Inspection
3. Hands
Is the patient well at rest? Check for clues around the bed Mobility aids O2 Cigarettes Medications eg. GTN Patient Age Signs of heart failure Cyanosis/Pallor
Temperature Tar Staining Capillary Refill Tendon Tendon / Palmar xanthoma xanthoma Radial Pulse (Rate, Rhythm, Character) BP in both arms
6. Leg Inspection Comparing right to left Dressings Scars Discolouration Pallor Missing hair / nails / toes Ulcers Non-healing injuries around pressure points Dry Skin Look in between toes and lift up feet patient to wiggle their toes Ask the patient (Motor dysfunction in acute ischaemia)
PALPATION (Ask about any pain first) Pulsatile ile mass mass Pulsat (Progressively deeper palpation above the umbilicus) Expansile ile mass mass Expans (Progressively deeper palpation both hands either side of the umbilicus)
MOUTH Central Cyanosis Angular Stomatitis
7. Leg Palpation ( Work distal to proximal)
Temperature: Compare both legs using the back of one hand Sensation: Get the patient to close close their eyes while testing Capillary refill: Squeeze both big toes for 3-5 seconds & release (Normal = less than or equal to 2 seconds) Pulses: Normal / Absent Absent / Reduced Reduced
8. Auscultation
9. To Finish
Femoral
* Carotid Pulse
Aortic Renal
Carotids
Thank patient Ask if they have any further questions Allow them to redress in private Further tests & investigations
DVT Examination 1. Introduction Wash Hands! Introduction Check pt name and ID Explain & Gain consent
6. Auscultation Lung bases For any signs of PE (reduced breath sounds heard)
7. To finish Thank patient Cover him up Mention investigations
2. General Inspection Look around the bed for: Wheelchair / walking aids Look at patient for: Fractures Signs of surgery and injury Pregnancy GTN spray Is patient breathless
5. Measure Use the measuring tape provided Mid calf, 10cm below tibial tuberosity Compare both legs at the SAME point If >3cm difference ⇒ significant for DVT scoring
3. Leg Inspection (compare both legs) Redness Swelling (you would expect these in DVT)
Varicose veins Ulceration Missing digits
4. Leg Palpation (compare both legs) Temperature (use back of hand) Tenderness Pitting Oedema Pulses (refer to arterial notes)
Things to note for OSCE discussion: 1. Possible Differentials Cellulitis • Ruptured Baker’s Cyst • Lymphoedema • Compartment Syndrome •
Varicose Veins Examination 1. Introduction Wash Hands! Introduction Check pt name and ID Explain & Gain consent
2. Inspection (patient is supine) Front of thigh to medial aspect of leg. This is the course of the long saphenous vein. Back of knee to the lateral malleolus. This is the course of the short saphenous vein.
For both these veins, look for : Asymmetry Swellings Scars Pigmentation (due to haemosiderin deposition)
7. Investigations Bloods Hand held Doppler Duplex ultrasound Colour flow Imaging
6. To finish Thank the patient Cover him up if you exposed him in the first place Mention any investigations you might do Take a history Check the peripheral pulses
3. Instructions to patient Do you have any difficulty standing? Can you please stand for me with your legs uncovered? This is done to make the varicosities more apparent. Re-inspect the leg with patient stood
4. Palpation Gently press on the varicosities and release to watch them refill. This confirms they are vascular. Note: Hard veins ~ thrombosis Painful veins ~ phlebitis
Use the back of your hand to feel the area around the varicosities. Varicosities are warm.
5. Special Tests Trendelenberg/Tourniquet Test (using a tourniquet) Purpose of this test : to determine the level of incompetency Ask patient if there is any pain in his leg before you raise it Milk the veins to drain them Locate the SFJ Use a tourniquet to occlude the SFJ Ask patient to stand up If varicosities refill the incompetent vein is lower Look at notes behind for other special tests
How to find the Sapheno-Femoral Junction Ask patient to lie down. Find the femoral pulse (midway between the ASIS and the pubic tubercle). The SFJ is located approximately 2cm medial and 2cm inferior to the femoral pulse. • •
•
2cm below and 2cm medial to femoral pulse
Tredelenberg & Torniquet Tests The aim is to locate the level of the incompetent valves. Lie the patient down and raise the affected leg attempting to drain the blood from the varicosities. Using either your fingers or a tourniquet put pressure over SFJ to occlude it. Ask patient to stand If varicosities do not refill immediately upon standing, it indicates the SFJ is incompetent. If they do refill, the incompetent valve is lower down. If they refill, you can continue testing to establish the level of the incompetency. Lie the patient down, raise and drain their leg. Place tourniquet a bit lower on thigh and repeat as before. If varicosities do not refill, this is the level of the incompetency. If varicosities do refill continue down leg. •
•
•
• •
• •
• •
•
•
Tap Test Ask the patient to stand up. Place one hand on the SFJ, the other on the varicosities. Tap the SFJ and feel for a thrill over the varicosities If a thrill is felt, it means there is backflow between the SFJ and the varicosities (i.e. incompetent valves). • •
• •
Cough Test Ask the patient to stand. Place fingers over SFJ and ask the patient to cough. If a thrill is felt, it suggests incompetence. • • •
Doppler Ultrasound Probe Test Place a Doppler probe at the SFJ. Squeeze calf muscle. Normal leg will produce a single Doppler ‘whoosh’ as the blood goes back to the heart. A leg with incompetent veins will give a second ‘whoosh’ as you stop squeezing, when the blood flows backwards in the veins. 1 whoosh is good, 2 whooshes are bad. This may be repeated in the Sapheno-Popliteal Junction. • • •
