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(1/2) CARDIOVASCULAR EXAMINATION Anya Olsen and Olivia Owen 1 GENERAL OSCE ADVICE FOR EXAMINATION STATIONS • Practice practice practice • Use a checklist • Watch examination videos • Read about the signs and what they mea– be ready to identify any pictures you see in the exam • Use the reading time • Think about your manner with the patient 2 CARDIO EXAM • Introduction • Inspection • Palpation • Percussion • Auscultation • Other areas (don’t forget the back and legs!) • Summary and offer additional tests Cardio exam includes all elements but better if you do a sequence hands arm – neck – face– chest – back and legs Image: https://www.istockphoto.com/vector/male-female-and-childrens-contour-on- white-background-vector-family-gm959089292-261890777 3 INTRODUCTION • Hand hygiene/PPE/clean stethoscope • Introduce self • Name and role • Confirm patient identity • Name and DOB • Explain examination • Gain consent • Position the patient (45 degrees) • Obtain adequate exposure (chest) • Ask about pain 4 GENERAL INSPECTION – FROMTHE END OFTHE BED • Patient’s bedside • GTN spray, oxygen delivery devices, ECG leads, IV medication, number of pillows • Patient • SOB,pallor,clamminess SOB, pallor, clamminess could all be signs of ACS SOB could be seen in congestive heart failure with pulmonary oedema 5 HANDS – SIGNS &WHATTHEY MEAN Answers in chat, spend around 1 min 6 HANDS (1) • Inspect • Pallor • Peripheral cyanosis • Tar staining • Koilonychia • Xanthomata • Signs of infective endocarditis: Janeway lesions,Osler’s nodes,splinter hemorrhages,petechial rash,clubbing • Scars Indicating previous radial artery harvesting for CABG (move onto pictures) 7HAND SIGNS Tar staining Peripheral cyano:spioor peripheral Koilonychi‘ pooning of the nails’ caused by perfusion e.g.,hypovolemia or inadequate iron deficiency anemia oxygenation e.g., righto-left shunting Pallore.g., Xanthomatacan be seen in familial shock/sepsis,anemia, hyperlipidemia congestive cardiac failure Talk through pics and what they mean Smoking and lipids = important CVD risk factors Peripheral cyanosis can also be seen in some respiratory conditions so Anya will go over these Pallor also indicates poor perfusion Sources Peripheral cyanosis: https:/www.physio-pedia.com/Cyanosis Tar staining: tps://bmjopen.bmj.com/content/3/11/e003304 Koilonychia: https://commons.wikimedia.org/wiki/File:Koilonychia_iron_deficiency_anemia.jpg Xanthomata: https://www.medicinenet.com/image- collection/xanthomatosis_2_picture/ icture.htm Pallor: https://tock.adobe.com/hu/search/images?k=pallor&asset_id=450909753 8HAND SIGNS– SIGNS OF INFECTIVE ENDOCARDITIS Janeway lesions: occur on Splinter hemorrhages Osler’s nodes red/purple, raisethe palms and soles,non pale centre,painful,usually foutender fingers or toes Clubbing: loss of ‘Schamroth’s window” (RHS) Lots of causes Petechial rash but IE is an important cause in the context of CV exam! Talk through images Other causes of clubbing: lung cancer, GI malignancy, IBD, lymphoma- but in the context of cardio exam infective endocarditis if you are shown this when examining a patient (also– congenital cardiac disease and atrial myxoma) Splinter hemorrhages can also be due to trauma, sepsis Sources: Osler’s nodes: https://dermnetnz.org/topics/osler-nodes-and-janeway-lesions Janeway lesions: Splinter haemorrhages, Osler's nodes, Janeway lesions and Roth spots: the peripheral stigmata of endocarditis September 2013 British journal of hospital medicine (London, England: 2005) 4(9):C139-42 Splinter haemorrhages: https://dermnetnz.org/topics/splinter-haemorrhage Petechial rash: https:/www.healthline.com/health/bleeding-into-the-skin#outlook Clubbing: Rosenberg JH, Saxena SK.Digital clubbing: an easily overlooked sign associated with systemic disease.Consultant. 2017;57(9):521-525. 9 HANDS (2) • Palpation • Assess temperature • Check CRT < 2 seconds • Measure right radial pulse (rate and rhythm) • 15 seconds if regular • 60 seconds if irregular • Do resp rate at the same time! • Palpate for radio-radial delay • OFFER to palpate for radio-femoral delay • Palpate for collapsing pulse Cool hands: poor perfusion. Could be due to congestive HF or if pale and clammy think ACS or shock/hypovolemia CRT: press for 5 and color should return in 2 seconds. If not also poor peripheral perfusion (same causes as above) Pulse rate and rhythm: Tachycardia: pain, shock, ACS, anxiety, hyperthyroidism Bradycardia: athletes, medications, hypothyroidism Irregular rhythm: AF = most common.Also heart block, ectopic beats If there is an irregular rhythm you should know difference between irregularly irregular (AF, ectopic) and regularly irregular (second degree heart block)– can do more detail if we go over ECG Palpate both radial pulses at the same time and the pulses should be simultaneous. If not think aortic dissection, coarctation of aorta, subclavian artery stenosis Offer radio-femoral delay: same causes as above Collapsing pulse: watch a video Right hand on radial pulse, left hand over brachial artery holding arm, remember to 10ask patient if there is any pain in the arm, raise their arm quickly and you're feeling for a bounding pulse or tapping against your fingers (main cause = aortic regurgitation) Image: https://geekymedics.com/cardiovascularexamination-2/ 10ABNORMAL HAND FINDINGS ON PALPATION Cool hands Irregular rhythm • Poor peripheral perfusion e.g., CCF • AF – most common cause (irregularly irregular) Cold and sweaty hands • Ectopic beats (irregularly irregular) • Shock • Heart block (can be regularly irregular or • ACS irregularly irregular) Prolonged CRT (> 2 seconds) Radio-radial delay • Shock • Coarctation of the aorta • Dehydration • Aortic dissection • CCF • Subclavian artery stenosis Rate abnormalities Radio-femoral delay • Bradycardia: heart block, medication • Coarctation of the aorta (beta-blockers,CCBs),athletic • Aortic dissection individuals,hypothyroidism • Tachycard : ia in, shock (low BP!), Collapsing pulse SVT,hyperthyroidism, AF,PE • Aortic regurgitation • High output cardiac failure (anemia, hyperthyroidism) 11 ARMS • Palpate brachial pulse (volume & character) • OFFER to measure BP in an OSCE (now or at the end) • Both arms • Lying and standing 12BLOOD PRESSURE Normalis around 120/80mmHg Hypertension>/= 140/90mmHg Hypotension</= 90/60mmHg Shock? Think shock if the systolic BP is less than the HR e.g. HR 65, BP 90/70 mmHg HR 110, BP 90/70mmHg HR 140, BP 115/85 >20mmHg difference between arms • Aortic dissection • Coarctation of the aorta Narrow pulse pressure(less than 25mmHg difference between systolic and diastolic BP) • Aortic stenosis, congestive heart failure, cardiac tamponade Wide pulse pressuremore than 100mmHg between systolic and diastolic BP) • Aortic dissection Mainly focus on hypotension/shock– important to be able torecogniseit and know what you would initially do Remember to know how to do manual BP Image: https://gograhamfield.com/blood-pressure-monitor-manual-automatic/ 13 NECK • Inspect JVP • Auscultate forcarotid bruit(or radiation of aortic stenosis murmur) • Use the bell on inspiration • Palpatecarotid pulse (volume & character) 2 things in the neck for cardio exam are carotids and JVP Auscultate carotids before palpation– if bruit present could be due to a thrombus or atheroma– wouldn’t wan to dislodge on palpation. 14JVP Internal jugular vein empties directly into RA, creating a continuous column of blood,RA pressure is reflected in the distention of IJV Don’t mix up with EJV! 1. Position patient at 45 degrees 2. Ask patient to look slightly to the left 3. Measure the distance from the sternal angle to the top of the pulsation of the JVP Normal JVP = 3cm or less Raised JVP • Right-sided heart failure • Tricuspid regurgitation • Constrictive pericarditis Just go through how to and what raised means Image https://epomedicine.com/clinicalmedicine/clinical-examination-jugular-venous- pulse-pressure-jvp/ 15CAROTID PULSE Auscultate for carotid bruit before palpation Diaphragm over carotid with patient in inspiration Sounds here could also be radiation of aortic stenosis murmur! If a carotid bruit is present– don’t palpate Pulse character NORMAL BOUNDING (aka‘Water hammer’): CO2 retention, aortic regurgitation THREADY: Hypovolemia, shock SLOW-RISING: Aortic stenosis For carotid pulse at the end of the examination you want to comment on the volume and character– most likely will be normal but here are some possibilities Sources for images http://www.palmcoastcardiology.com/index.php/about-us/our-services/226-carotid- ultrasound https://www.clinicianrevision.com/courses/cardiology/lessons/cardiovascul- r examination/topic/pulsecharacter/ https://www.osmosis.org/learn/Pulse:_Clinical_skills_notes 16 FACE • Inspection:eyes • Conjunctival pallor, corneal arcus, xanthelasma • Inspection:face • Malar flush • Inspection:mouth • Central cyanosis, angular stomatitis, high arched palate, dental hygiene(poor dental hygiene is associated with infective endocarditis) Other signs include - high arched palate (associated with Marfan's which can increase risk of aortic dissection and valve prolapse) 17FACE SIGNS Xanthelasmais associated with Corneal arcusis associated hyperlipidemia with hyperlipidemia Conjunctival palloris associated with iron deficiency anemia Malar flushis associated with mitral stenosis Central cyanosiscan be seen in hypoxiae.g.due to right-to-left shunting Sources for images: Corneal arcus: https://webeye.ophth.uiowa.edu /eyeforum/atlas/pages/Arcus/ndex.htm Xanthelasma: https://www.aao.org/eye-health/diseases/whatis-xanthelasma Conjunctival pallor: https://www.shutterstock.com/search/pallor Malar flush: https://www.healthline.com/health/malar-rash Central cyanosis: https://static1.squarespace.com/static/5871553a3e00be90c79a68cd/t/58c2cacfbeba fb1001f8a450/1489160912584/RESP16.pdf https://dftbskindeep.com/all-diagnoses/centralcyanosis/ 18 CHEST - INSPECTION • Don’t forget about the sides of the chest! • Scars • Pulsations • Deformities (more details in resp exam) Pulsations can be seen in thin people usually or they can be a sign of pathologye.g. left ventricular aneurysm 19CHEST SCARS Relevant to both cardio and resp exams https://geekymedics.com/cardiothoracicncisions/ 20 CHEST – PALPATION • Apex beat th • Normal = 5 ICS,midclavicular line • Displaced in ventricular hypertrophy • Heaves • Apical heave can be due to left ventricular hypertrophy • Left parasternal heaves are usually due to right ventricular hypertrophy • Thrills • Thrill = palpable murmur • Palpate with 2/3 fingers in the same 4 areas as auscultation Apex – should be mid clavicular line 5th intercostal space Displaced can be due tohypertrophy usually. Lots of cause: LVH can be due to HTN, HF/ RVH can be due to lung disease. And valvular disease can also cause RVH or LVH depending on the valve Heaves present in right ventricular hypertrophy (cor pulmonale) Thrills are palpable murmurs 21 CHEST – AUSCULTATION • Bell & diaphragm in all 4 areas • Mitral: 5 ICS mid-clavicular line • Tricuspid: 4/CS lower left sternal edge nd • Pulmonary: 2 ICS left sternal edge • Aortic: 2 ICS right sternal edge • Palpate carotid simultaneously to distinguish S1/S2 • Maneuvers to accentuate murmurs… Image: https://geekymedics.com/cardiovascularexamination-2/ 22 ADDITIONAL MANEUVERS Watch a video! 1. Bell at the apex, ask patient to roll onto left side and hold breath on expiration (MS) 2. Diaphragm in axilla (MR) 3. Ask patient to lean forwards, auscultate the lower left sternal edge with the diaphragm and ask the patient to hold their breath on expiration (AR) 4. (Auscultate over the carotids with the diaphragm in inspiration– should have already been done before palpation of carotid- can reveal carotid bruits or radiation ofAS murmur) Mitral stenosis STAYS at the apex Mitral regurgitation RADIATES to the axilla 23Good website for listening to m:ttps://www.lecturio.com/concepts/hear-tounds/ EXTRA SOUNDS Normal =HS1 + HS2 + 0 S3 can indicate heart failure SYSTOLIC MURMURS DIASTOLIC MURMURS Aortic stenosis Aortic regurgitation • Ejection systolic murmur • Early diastolic murmur • Radiates to carotids • Loudest at the lower left sternal edge with • Associated slow-rising pulse the patient sat forward in inspiration,using the diaphragm Mitral regurgitation • Associated collapsing pulse • Pan-systolic murmur • Radiates to axilla Mitral stenosis • Mid-late diastolic murmur Ventricular septal defect • Louder in left lateral position in held • Pan-systolic murmur expiration,using the bell • Associated malar flush Go over systolic vs diastolic You use where it is loudest/radiation/maneuvers and associated features to determine what the murmur is Image: https://en.wikipedia.org/wiki/Heart_sounds 24 BACK • Inspection • Scars • Palpation • Sacral oedema • Right-sided heart failure • Auscultation • Lung bases • The presence of coarse crackles could indicate pulmonary oedema secondary to left-sided heart failure 25 LEGS • Inspection/palpation • Ankle oedema • CCF • Scars • Saphenous vein harvesting for CABG Images: https://en.wikipedia.org/wiki/Edema Saphenous vein harvesting site dermatoses in eastern India Sudip Kumar Ghosh MD DNBDDermat, Debabrata Bandyopadhyay MD Dermatology Online Journal 15 (7): 13 26 OTHER AREAS • Things to offer in the OSCE station“for completeness I would like to…” • Measure BP • Inspect abdomen • Palpate and percuss for hepatomegaly • Auscultate for renal and femoral bruits • Palpate for radio-femoral delay • Peripheral vascular examination • Ophthalmoscopy (look for hypertensive retinopathy or Roth’s spots indicating infective endocarditis) • Urine dip (HTN, endocarditis can cause protein and blood in urine) • Ask to see the patient’s observation chart 27 CONCLUSION • Thank patient and allow them to r-eress • Hand hygiene/remove PPE/clean stethoscope • Present summary of findings to examiner (1 minute) 28 EXAMPLE SUMMARY • Today I did a cardiovascular examination on XXX, who is XX years old. They presented with XXX.On general inspection there was no medication or equipment around the patient,and clubbing,Janeway lesions,Osler's nodes or oedema. The radial pulse was regular in rhythm and the rate was XX beats per minute,there was no collapsing pulse.The JVP was not raised,there were no carotid bruits,and the the carotid pulse was normal in volume and character.On inspection of the chest there were no scares,deformities or visible pulsations.The apex was in the 5 IC space in the midclavicular line and there were no heaves or thrills.On auscultation, heart sounds 1 and 2 were present with no additional sounds,including wen maneuvers were To conclude this was a normal cardiovascular examination. Additional tests I would like to do would be… (12 lead ECG,troponins,CXR) • Also comment on observation chart during your summary Practice this Run through examination and what you were looking for at each stage Tailor your summary to the patient’s presentation e.g., if the scenario is to examine for signs of infective endocarditis Whereas if they were asking you to examine for HFoulldemonstrate how you were looking for peripheral cyanosis, prolonged CRT, raised JVP, third heart sound, heaves, crackles in the lung bases, ankle and sacral oedema If there is no scenario and they just askyoutto examine the CV system, then you can just mention generally what you were looking for 29 (2/2) PERIPHERALVASCULAR EXAMINATION Anya Olsen and Olivia Owen Easy and lots of overlap with CV exam with a few new concepts 30 PERIPHERALVASCULAR EXAM • Introduction • General inspection • UL • Neck • Face • Abdomen • LL • Doppler • Other tests • Conclusion Cardio exam includes all elements but better if you do a sequence hands arm – neck – face– chest – back and legs Image: https://www.istockphoto.com/vector/male-female-and-childrens-contour-on- white-background-vector-family-gm959089292-261890777 31 INTRODUCTION • Hand hygiene/PPE/clean stethoscope • Introduce self • Name and role • Confirm patient identity • Name and DOB • Explain examination • Gain consent • Position the patient (45 degrees) • Obtain adequate exposure (arms and legs, abdomen) • Ask about pain Exp: look at hands face tummy and legs, feel pulses, few extra tells will explain as I go along 32 GENERAL INSPECTION What are you looking for? •Around the patient: motility aids, medications, oxygen, cigarettes, observation chart •Patient: missing limbs, gangrene, dressings, cellulitis, pallor, leg position, body habitus 33GENERAL INSPECTION– around the patient , mobility aids, vital signs, medication, prescription, medical devices 34GENERAL INSPECTION– the patient Also–obvious signs of pain Missing limbs, obvious scars, Limb prosthesis, dressings Links to images Amputee https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.orlandohealth.com%2 Fcontent-hub%2Fwhat-happens-when-the-limb-is-gone-but-the-pain- remains&psig=AOvVaw0towvaGZvnlgCLDAex2amd&ust=1667861496526000&source =images&cd=vfe&ved=0CAwQjRxqFwoTCIiUhrPSmvsCFQAAAAAdAAAAABAD Gangrene https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.docfoot.com%2Fblog %2Fgangrene&psig=AOvVaw2EnSxh86xJ4b7U5VkLxrS- &ust=1667861525728000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCLiP_8HS mvsCFQAAAAAdAAAAABAD 35Dressing https://www.google.com/url?sa=i&url=https%3A%2F%2Fbonesmart.org%2Fwound- care-in-the-hospital%2F&psig=AOvVaw0i_7kz- fTWQWrZVpUVEOh&ust=1667861564968000&source= images&cd=vfe&ved=0CAwQj RxqFwoTCLCp3dPSmvsCFQAAAAAdAAAAABAD Critical limbischaemia https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.researchgate.net%2Ffi gure%2FThe-position-of-a-critical-limb-ischemia-patient-on-a- bed_fig1_259883644&psig=AOvVaw3ULanbbrcUae61FhNFyoJs&ust=1667861865363 000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCPCP8eHTmvsCFQAAAAAdAAAA ABAD 35 WHAT IS THE SIGNIFICANCE OF THIS IMAGE? Critical limb ischemia, patient hangs leg out of bed to improve BF (effect of gravity) and reduce pain which would be worse on laying with legs up 36 A LITTLE BIT ABOUT PERIPHERAL VASCULAR DISEASE • Phases of PVD 1. Intermittent claudication 2. Critical limb ischaemia 3. Acute limb-threatening ischaemia • 1. Intermittent claudication • Pain in the legs on walking, occurs after a specified amount of time/distance, relieved by rest/no pain at rest • Investigations: vascular examination, ABPI, duplex US, MR angiography 2. Critical limb ischaemia • Patients have at least one of (a) rest pain for at least 2 weeks (b) gangrene (c) ulcert nii n.t, patients might hang their legs out of bed to keep blood flow (via .n ABPI < 0.5 indicates severe limb ischaemia 3. Acute limb-threatening ischaemia • Investigations include handheld doppler US, if pulses found, ABPI can be calculated.hingly cold • Management: IV opioids (analgesia), IV unfractioned heparin, vascular review (thrombolysis/embolectomy/angioplasty/bypass surgery/amputation for patients with irreversible ischaemia) Notes modified fromPassmed.com 37 THE UPPER LIMB • Inspection • Palpation • Temperature • CRT • Radial pulse (rate and rhythm,assess for radio -radial delay) • Palpate ulnar arteries • Brachial pulse (IFWEAK ORABSENT RADIAL PULSE) • Allen’s test (IF ULNARARTERIES NOT PALPABLE) • BP on both arms •Inspect for vasodilation, peripheral cyanosis, Raynaud's, tar staining, xanthomata, gangrene, pallor • Pallor and peripheral cyanosis can indicate PVD • Tar staining = risk factor for PVD • Xanthomata indicates high cholesterol- risk factor for PVD • Gangrene = tissue necrosis secondary to inadequate perfusion. Discolouration of the tissue can be red or black •Palpate for warmth (both sides: hands, forearms and arms) • Both UL should be symmetrically warm • Cool pale limb indicates inadequate perfusion •Palpate CRT • Press for 5, colour should return in 2 •Palpate radial pulse (rate and rhythm) •Assess for radio-radial delay • Radio-radial delay could be due to aortic dissection or subclavian artery stenosis (e.g., due to cervical rib) •Palpate ulnar arteries •Palpate brachial pulse (bilaterally only necessary if radial pulse absent or very weak) • Located medial to biceps tendon •Allen's test (only necessary if ulnar artery not palpable) 38•Offer BP on both arms • Wide pulse pressure (>20mmHg difference between SBP and DBP) indicates aortic regurgitation or aortic dissection • More than 20mmHg difference between arms indicates aortic dissection 38UPPER LIMB- INSPECTION Tar staining Peripheral cyanosis Gangrene Pallor Xanthomatacan be seen in familial hyperlipidemia •Inspect for vasodilation, peripheral cyanosis, Raynaud's, tar staining, xanthomata, gangrene, pallor • Pallor and peripheral cyanosis can indicate PVD • Tar staining = risk factor for PVD • Xanthomata indicates high cholesterol- risk factor for PVD • Gangrene = tissue necrosis secondary to inadequate perfusion. Discolouration of the tissue can be red or black 39 UL - PALPATION (AND OTHER THINGS) • Temperature • CRT • Radial pulse (rate and rhythm, assess for rad-radial delay) • Palpate ulnar arteries • Palpate brachial arteries (IFABSENT ORWEAK RADIAL PULSE) • Allen’s test (IFABSENT ORWEAK ULNAR PULSE) • BP on both arms Brachial artery location Question: what is Allen’s test for? •Manchester notes say brachial only required if radial weak or absentother places such as geeky medics say to do it so check with your medical school for exam– at the very least mention to examiner that radial pulse is present and if it was not you would palpate the brachial pulse– can check if examiner wants you to do it anyway •Palpate for warmth (both sides: hands, forearms and arms) • Both UL should be symmetrically warm • Cool pale limb indicates inadequate perfusion •Palpate CRT • Press for 5, colour should return in 2 •Palpate radial pulse (rate and rhythm) •Assess for radio-radial delay • Radio-radial delay could be due to aortic dissection or subclavian artery stenosis (e.g., due to cervical rib) •Palpate ulnar arteries •Palpate brachial pulse (bilaterally only necessary if radial pulse absent or very weak) • Located medial to biceps tendon •Allen's test (only necessary if ulnar artery not palpable) •Offer BP on both arms 40• Wide pulse pressure (>20mmHg difference between SBP and DBP) indicates aortic regurgitation or aortic dissection • More than 20mmHg difference between arms indicates aortic dissection 40ALLEN’STEST– assess collateral blood flow to the hands https://youtu.be/D1tJO0RW9UM (watch yt video) Assessing collateral BS to the hand 41 NECK AND FACE • Palpation • Carotid (character and volume) • One side at a time • Auscultate • For carotid bruits • Inspect face • Corneal arcus • Xanthelasma Location or carotid arteries Neck •Palpate carotid pulse (character and volume– see CV exam slide on carotid pulse • Slow rising pulse in aortic stenosis • Thready pulse in hypovolaemia/sepsis •Auscultate for carotid bruits • Could be carotid artery stenosis, a vascular surgical problem • Could be a radiating cardiac murmur so if present, also listen to HS Face •Inspect for xanthelasma and corneal arcus Image https://www.google.com/url?sa=i&url=https%3A%2F%2Fmeded.ucsd.edu%2Fclinical med%2Fheart.html&psig=AOvVaw0cWz1xzH8dgaewUwlUJ2- q&ust=1667933434203000&source= images&cd=vfe&ved=0CAwQjRxqFwoTCKjzorLen PsCFQAAAAAdAAAAABAN 42 ABDOMEN • Inspection • Surgical scars • Visible pulsations • Palpation • Pulsatile mass • Auscultation • Aortic and renal bruits Question: if a patient has a visible pulsation on the abdomen and a palpable pulsatile masis?gnot is your differentialsd Abdomen •Inspect for surgical scars, visible pulsations •Palpate for AAA •Palpate superior to the umbilicus in the midline • In healthy individuals your hand should begin to move superiorly with each pulsation • In AAA, fingers will move outwards •Auscultate abdominal aorta •Auscultate for renal bruits • Bruits of renal arteries or abdominal aorta indicate turbulent blood flow e.g. AAA/renal artery stenosis Image https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.nejm.org%2Fdoi%2Ffu ll%2F10.1056%2FNEJMvcm1406358&psig=AOvVaw3YEzj4KJnrANSXrAuXkaEZ&ust=16 67933555951000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCNCyoevenPsCFQA AAAAdAAAAABAD 43 LL • Inspection:front and back of leg,inbetween toes,sole of foot,heel • Palpation • Auscultation (femoral pulse only offer this in an OSCE) Question: what do you look for on close inspection of the lower limb? Lower limb •Inspect and compare the lower limbs: gangrene, missing digits, cellulitis, hair loss, arterial or venous ulcers, scars, varicose veins, venous eczema, Lipodermatosclerosis, peripheral cyanosis, peripheral pallor, ischaemic rubour, muscle wasting, xanthomata (whole leg, back of leg, heels, in-between toes) • Ischaemic rubour is a dusky red appearance due to loss of capillary tone seen in PVD • Venous ulcers: large, shallow, irregular borders, mildly painful. Venous ulcers commonly develop over the medial aspect of the ankle • Arterial ulcers: small, deep, wel-defined, very painful. Most commonly develop in the most peripheral regions of the LLe.g.digits • Hair loss occurs in PVD due to chronic inadequate tissue perfusion • Muscle wasting: chronic PVD •Palpate for temperature (whole leg and foot) • Both LL should be symmetrically warm •Palpate CRT •Palpate dorsalis pedis both sides • Lateral to extensor hallucis longus tendon •Palpate posterior tibial both sides • Postero-inferior to medial malleolus 44•Palpate popliteal both sides • Thumbs on tibial tuberosity, curl fingers into the popliteal fossa and press against posterior tibia •Palpate femoral (offer to do this in OSCE) •Assess for radio-femoral delay (offer to do this in OSCE) •Auscultate femoral pulse (offer to do this in OSCE) • Bruit indicates iliac or femoral stenosis 44LOWER LIMB– INSPECTION (arterial disease) Muscle wasting Arterial ulcer Ischemic rubour Amputated digits ALSO: gangrene, missing digits, peripheral cyanosis, peripheral pallor, xanthomata, Ischaemic rubor https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.researchgate.net%2Ffi gure%2FTypical-photo-of-dependent-rubor-ischemic-rubor-This-reddish-color- disappears- by_fig2_329401014&psig=AOvVaw3eoihM9_wzFcFDI27ME6Aa&ust=1667863056388 000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCKjggJ7YmvsCFQAAAAAdAAAAA BAO Venous ulcer https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.woundsource.com%2F patientcondition%2Fvenous ulcers&psig=AOvVaw3dfGnDvyhvwht7UDG9ZgWm&ust=1667863137095000&source =images&cd=vfe&ved=0CAwQjRxqFwoTCLjo2MDYmvsCFQAAAAAdAAAAABAD Arterial ulcer https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.vascularsociety.org.uk 45%2Fpatients%2Fconditions%2F12%2Farterial_ulcer&psig=AOvVaw3QiF0H4GlulCJe4f_ rziO8&ust=1667863169195000&source= images&cd=vfe&ved=0CAwQjRxqFwoTCNj5 gNHYmvsCFQAAAAAdAAAAABAI Muscle wasting https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.news- medical.net%2Fnews%2F20180313%2FMuscle-wasting-of-old-age-and-ways-to-stop- it-understood-in-new- study.aspx&psig=AOvVaw3gYWyHIOxvWxl7y5m2Z41K&ust=1667925945686000&sou rce=images&cd=vfe&ved=0CAwQjRxqFwoTCIC878HCnPsCFQAAAAAdAAAAABAD Hair loss https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.facebook.com%2FBra dHillMD%2Fphotos%2Fa.2433590126859398%2F2960942394124166%2F%3Ftype%3 D3&psig=AOvVaw2bNdlyXk- wxqeZzMCWeGvM&ust=1667925992111000&source=images&cd=vfe&ved=0CAwQj RxqFwoTCIixiNvCnPsCFQAAAAAdAAAAABAO 45LOWER LIMB– INSPECTION (venous disease) Venous eczema Venous ulcer Varicose veins Question: How do you differentiate between arterial and venous ulcers? Venous eczema https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.pcds.org.uk%2Fclinical -guidance%2Feczema-gravitational-eczema-syn-varicose-eczema-or-stasis- dermatitis&psig=AOvVaw29WPw4N - mMgLtJS0u5u6rn&ust=1667864249851000&source=images&cd=vfe&ved=0CAwQjRx qFwoTCNiem9TcmvsCFQAAAAAdAAAAABAD Venous ulcer https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.woundsource.com%2F patientcondition%2Fvenous ulcers&psig=AOvVaw3dfGnDvyhvwht7UDG9ZgWm&ust=1667863137095000&source =images&cd=vfe&ved=0CAwQjRxqFwoTCLjo2MDYmvsCFQAAAAAdAAAAABAD Varicose veins https://www.google.com/url?sa=i&url=https%3A%2F%2Fccveins.com%2Fwhy-are- women-more-susceptible-to-varicose- veins%2F&psig=AOvVaw1dg2Vi35Qx4P0Ml4KBSP7g&ust=1667864204041000&sourc e=images&cd=vfe&ved=0CAwQjRxqFwoTCODBgsHcmvsCFQAAAAAdAAAAABAD 46ARTERIAL ULCERS VENOUS ULCERS Deep Shallow Well demarcated Irregular edges Extremely painful Mildly painful Occurs in most peripheral region of limb e.g. dOccurs most commonly over medial malleolus Smaller Larger 47 LOWER LIMB – PALPATION AND AUSCULTATION • Palpation • Temperature • CRT • Pulses (compare both sides) • Dorsalis pedis • Posterior tibial • Popliteal • Femoral and assessment for radiofemoral delay (only OFFER this in OSCE) • Auscultation • Femoral pulse (only OFFER this in OSCE)bruit could be due to femoral or iliac stenosis 48LOWER LIMBARTERIAL PALPATION-Anatomy Dorsalis pedis https://www.google.com/url?sa=i&url=https%3A%2F%2Fmedicaldialogues.in%2Fsurg ery%2Fnews%2Fpalpae-potami-the-new-proposed-method-for-locating-the-dorsalis- pedis-artery- 72317&psig=AOvVaw31xG2ZAE363dOmYMGLprgO&ust=1667864783245000&source =images&cd=vfe&ved=0CAwQjRxqFwoTCNC5-dHemvsCFQAAAAAdAAAAABAD Posterior tibial https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.researchgate.net%2Ffi gure%2FFig24-The-relations-of-the-posterior-tibial-artery-as-it-passes-behind-the- medial_fig11_334430114&psig=AOvVaw1fRBpR7E2gqBfdbDiN0ifc&ust=1667864830 747000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCLjU_unemvsCFQAAAAAdAA AAABAI Popliteal pulse https://www.google.com/imgres?imgurl=https%3A%2F%2Fwww.wikihow.com%2Fim ages%2Fthumb%2F1%2F16%2FFind-the-PoplitealPulse-Step-2.jpg%2Fv4-460px-Find- the-PoplitealPulse-Step- 2.jpg&imgrefurl=https%3A%2F%2Fwww.wikihow.com%2FFind-the-Popliteal 49Pulse&tbnid=8YZHc0aRQcGwpM&vet=12ahUKEwjswPyi35r7AhU8hM4BHV2ZC4cQM ygKegUIARD1AQ..i&docid=N3 pszSEwRxqVM&w=460&h=345&q=popliteal%20pulse&clients fari&ved=2ahUKEwjs wPyi35r7AhU8hM4BHV2ZC4cQMygKegUIARD1AQ https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.umcvc.org%2Fconditi ons-treatments%2Fpopliteal-artery-entrapment- syndrome&psig=AOvVaw0mLfyQ4lfVcZOtlFLnm3UQ&ust=1667864955617000&sourc e=images&cd=vfe&ved=0CAwQjRxqFwoTCPimx7HfmvsCFQAAAAAdAAAAABAD Femoral pulse https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.bdu.ac.in%2Fschools% 2Fbiotechnology-and-genetic-engineering%2Fbiomedical- science%2Fdocs%2Fcourse_materials%2Fcardiovascular_biology%2FArtery_pulse.pdf &psig=AOvVaw15-giqtkXU- IQ8k8otnwuu&ust=1667865053643000&source=images&cd=vfe&ved=0CAwQjRxqF woTCNi4mNffmvsCFQAAAAAdAAAAABAD 49 DOPPLER • Dorsalis pedis and posterior tibial • Listen for triphasic waveform sound • Monophasic– abnormal • Watch YT video + practice! https://youtu.be/ZKwdN3oRCIfrom 0:19 50 OTHER TESTS • Buerger’s test (rarely used, limited use) • Gross motor assessment • Gross sensation assessment Other •Buerger's test (rarely used, limited use) • Patient supine • Raise legs to 45 degrees for 1-2 minutes • Observe the colour of the limbs • Development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity • Not the angle that the pallor develops (the Buerger's angle) • Buerger's angle of less than 20 degrees indicates severe limb ischaemia • In a normal patient, legs should remain pink, even at 90 degrees • Sit the patient up and hang their legs over the end of the bed • Gravity aids reperfusion of leg and restoration of colour • The leg will initially turb blue-ish due to passage of deoxygenated blood through ischaemic tissue then red due to reactive hyperaemia •Ask patient to wiggle toes (gross motor) •Gross sensation (use cotton wool from distal to proximal on both sides) • PVD causes a glove and stocking sensory loss • Test sensation witch a cotton wool from distal to proximal until the patient can feel it • (ask patient to close eyes and say yes when they feel it–compare side to side) 51•If sensation is intact distally, no further assessment is required. •If there is a sensory deficit, continue to move proximally until the patient is able to feel the cotton wool and note the level at which this occurs. 51BUERGER’STEST (Images from Geeky Medics) 1. 2. 3. •Buerger's test (rarely used, limited use) • Patient supine • Raise legs to 45 degrees for 1-2 minutes • Observe the colour of the limbs • Development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity • Not the angle that the pallor develops (the Buerger's angle) • Buerger's angle of less than 20 degrees indicates severe limb ischaemia • In a normal patient, legs should remain pink, even at 90 degrees • Sit the patient up and hang their legs over the end of the bed • Gravity aids reperfusion of leg and restoration of colour • The leg will initially turb blue-ish due to passage of deoxygenated blood through ischaemic tissue then red due to reactive hyperaemia 52 TO CONCLUDE • Thank the patient • Allow them to re -dress • Present findings to examiner • https://geekymedics.com/peripheral -vascular-examination/ has good example summaries • Offer additional tests • ABPI • BP measurement • CV examination • Neurological examination of upper and lower limb 53QUIZTIME!! 54 EXAMINATION FINDINGS MOST CONSISTENTWITH HEART FAILURE A. Collapsing pulse, early diastolic murmur B. Slow-rising pulse,narrow pulse pressure C.Osler’s nodes,splinter hemorrhages,new pansystolic murmur D. Raised JVP, bilateral coarse crackles in lung bases, ankle oedema E. Pale,clammy patient with tachycardia and no other examination findings D Collapsing pulse and early diastolic murmur = aorticregurg Slow rising pulse and narrow pulse pressure = aortic stenosis Oslers nodes, splinterhamorrhages, new murmur = infective endocarditis E – ACS 55 EXAMINATION FINDINGS MOST CONSISTENTWITH HEART FAILURE A. Collapsing pulse, early diastolic murmur B. Slow-rising pulse,narrow pulse pressure C.Osler’s nodes,splinter hemorrhages,new pansystolic murmur D. Raised JVP, bilateral coarse crackles in lung bases, ankle oedema E. Pale,clammy patient with tachycardia and no other examination findings D Collapsing pulse and early diastolic murmur = aorticregurg Slow rising pulse and narrow pulse pressure = aortic stenosis Oslers nodes, splinterhamorrhages, new murmur = infective endocarditis E – ACS 56 A 38 -YEAR -OLD PATIENT WITH KNOWN PERIPHERALVASCULAR DISEASE PREST IN HIS LEFT LEG. HE IS A SMOKER. HIS BMI IS 25 KG/M² AND HE HAS NO OTHER MEDICAL HISTORY. ON EXAMINATION, HE HAS ABSENT FOOT PULSES AND LOWER LIMB PALLOR AS WELL AS AN ASYMMETRICALLY COOL LEFT LEG. WHAT IS THE MOST LIKELY DIAGNOSIS? A. Critical limb ischemia B. Intermittent claudication C.Varicose veins D. Acute lim-threatening ischemia E.Deep vein thrombosis Modifedfrom geeky medics Correct answer is D due to as presence of pain, pallor, pulselessness 57 A 38 -YEAR -OLD PATIENT WITH KNOWN PERIPHERALVASCULAR DISEASE PRREST IN HIS LEFT LEG. HE IS A SMOKER. HIS BMI IS 25 KG/M² AND HE HAS NO OTHER MEDICAL HISTORY. ON EXAMINATION, HE HAS ABSENT FOOT PULSES AND LOWER LIMB PALLOR AS WELL AS AN ASYMMETRICALLY COOL LEFT LEG. WHAT IS THE MOST LIKELY DIAGNOSIS? A. Critical limb ischemia B. Intermittent claudication C.Varicose veins D. Acute lim -tbreatening ischemia E.Deep vein thrombosis Modifedfrom geeky medics Correct answer is D due to as presence of pain, pallor, pulselessness 58 DIFFERENTIAL DIAGNOSIS FOR A PATIENTWITH ACUTE CHEST PAIN, SOB, CLAMMINESS AND NO OTHER FINDINGS O/E (PMH INCLUDES HTN AND DIABETES) A. PE B. ACS C. Congestive heart failure D. Atrial fibrillation E. Infective endocarditis B PMH = risk factors for ACS and symptoms are typical– there are usually no examination findings and observations can be normatachyespecially if smaller MI PE – pleuritic chest pain,haemoptysis, tachycardia, tachypnea.Usually recent surgery or immobility or patient taking HRT/contraceptive pill C – usually not painful D – usually palpitations are the presenting complaint IE – usually the patient is generally unwell with a fever and has a new murmur & peripheral signs 59 DIFFERENTIAL DIAGNOSIS FOR A PATIENTWITH ACUTE CHEST PAIN, SOB, CLAMMINESS AND NO OTHER FINDINGS O/E (PMH INCLUDES HTN AND DIABETES) A. PE B. ACS C. Congestive heart failure D. Atrial fibrillation E. Infective endocarditis B PMH = risk factors for ACS and symptoms are typical– there are usually no examination findings and observations can be normatachyespecially if smaller MI PE – pleuritic chest pain,haemoptysis, tachycardia, tachypnea.Usually recent surgery or immobility or patient taking HRT/contraceptive pill C – usually not painful D – usually palpitations are the presenting complaint IE – usually the patient is generally unwell with a fever and has a new murmur & peripheral signs 60 A 77 -YEAR -OLD MAN WITH A BACKGROUND OF DIABETES, HYPERTENSION, HYPERCHOLESTEROLAEMIA AND PREVIOUS MYOCARDIAL INFARCTION (MI) SEES HIS GP ABOUT INTERMITTENT ABDOMINAL PAINTHAT HE HAS BEEN HAVING FOR TWO MONTHS. IT IS EXAMINATION, HE HAS A PULSATILE EXPANSILE MASS INTHE CENTRAL ABDOMEN. DIFFERENTIAL DIAGNOSIS? A.Aortic dissection B. Angina pectoris C.Abdominal aortic aneurysm D. Mesenteric ischemia E.Irritable bowel syndrome 61 A 77 -YEAR -OLD MAN WITH A BACKGROUND OF DIABETES, HYPERTENSION, HYPERCHOLESTEROLAEMIA AND PREVIOUS MYOCARDIAL INFARCTION (MI) SEES HIS GP ABOUT INTERMITTENT ABDOMINAL PAINTHAT HE HAS BEEN HAVING FOR TWO MONTHS. IT IS EXAMINATION, HE HAS A PULSATILE EXPANSILE MASS INTHE CENTRAL ABDOMEN. DIFFERENTIAL DIAGNOSIS? A.Aortic dissection B. Angina pectoris C.Abdominal aortic aneurysm D. Mesenteric ischemia E.Irritable bowel syndrome 62 AORTIC DISSECTION IS MOST LIKELY IF WHICH OFTHE FOLLOWINGARE PRESENT? A. Narrow pulse pressure, slow rising pulse B. Collapsing pulse C.Raised JVP D. Radi- adial delay E.Continuous machinery murmur D – radio-radial delay 63 AORTIC DISSECTION IS MOST LIKELY IF WHICH OFTHE FOLLOWINGARE PRESENT? A. Narrow pulse pressure, slow rising pulse B. Collapsing pulse C.Raised JVP D. Radi- adial delay E.Continuous machinery murmur D – radio-radial delay 64A 65 -YEAR -OLD MAN WITH A BACKGROUND OF HYPERTENSION IS BROUGHT IN BYAMBULANCETOTHE EMERGENCY DEPARTMENT WITH SUDDEN -ONSET RIPPING CHEST PAIN AND ASSOCIATED DIAPHORESIS AND ARMWEAKNESS. ON EXAMINATION HE APPEARS APPREHENSIVE AND DISTRESSED WITH PAIN NOT MANAGED EVEN BY IV MORPHINE.THE BLOOD PRESSURE IN HIS LEFT ARM IS 184/102 MMHG,WHILST IN HIS RIGHT ARM IT IS 147/97 MMHG. DIFFERENTIAL DIAGNOSIS? A. Mitral regurgitation B.Aortic stenosis C.Acute heart failure D. Aortic dissection E.Myocardial infarction 65A 65 -YEAR -OLD MAN WITH A BACKGROUND OF HYPERTENSION IS BROUGHT IN BYAMBULANCETOTHE EMERGENCY DEPARTMENT WITH SUDDEN -ONSET RIPPING CHEST PAIN AND ASSOCIATED DIAPHORESIS AND ARMWEAKNESS. ON EXAMINATION HE APPEARS APPREHENSIVE AND DISTRESSED WITH PAIN NOT MANAGED EVEN BY IV MORPHINE.THE BLOOD PRESSURE IN HIS LEFT ARM IS 184/102 MMHG,WHILST IN HIS RIGHT ARM IT IS 147/97 MMHG. DIFFERENTIAL DIAGNOSIS? A. Mitral regurgitation B.Aortic stenosis C.Acute heart failure D. Aortic dissection E.Myocardial infarction 66 DIFFERENTIAL DIAGNOSIS FOR A PATIENTWITH PALPITATIONS, SOB AND IRREGULARLY IRREGULAR PULSE O/E (PMH INCLUDES HYPERTHYROIDISM) A. Supraventricular tachycardia B. Ventricular tachycardia C. Atrial flutter D. Atrial fibrillation E. 2 degree heart block D SVT and VT are regular/achyusually Atrial flutter is can be regular (most likely) or irregular nd 2 degree heart block can be irregularly irregular (Mobitz 2) or regularly irregular (Mobitz 1) AF is irregularly irregular and a common complication of hyperthyroidism 67 DIFFERENTIAL DIAGNOSIS FOR A PATIENTWITH PALPITATIONS, SOB AND IRREGULARLY IRREGULAR PULSE O/E (PMH INCLUDES HYPERTHYROIDISM) A. Supraventricular tachycardia B. Ventricular tachycardia C. Atrial flutter D. Atrial fibrillation E. 2 degree heart block D SVT and VT are regular/achyusually Atrial flutter is can be regular (most likely) or irregular nd 2 degree heart block can be irregularly irregular (Mobitz 2) or regularly irregular (Mobitz 1) AF is irregularly irregular and a common complication of hyperthyroidism 68 RECOMMENDED RESOURCES • Geeky medics notes and videos • Cardiovascular ex: ttps://geekymedics.com/cardiovascularxamination- 2/ • Oxygen delivery devices: https://oxfordmedicaleducation.com/prescribing/oxygedelivery/ • OSCEStop • Cardiovascular ex: ttps://oscestop.com/Cardiac_Exam.pdf 69 SOURCES https://geekymedics.com/cardiovascularxamination-2/ https://geekymedics.com/peripheral ascular-examination/ We do not own any of the i– taeysave solely been used to demonstrate the conditions spoken about 70 FEEDBACK FORMS • We would be very grateful if you can fill out the feedback form (link in chat/ email fromMedAll • Slides and certificates of attendance will be made available on completion of the feedback form 71