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Hand exam & Peripheral pulses Sarah CarrollPeripheral pulses  7 pulses  Radial  Brachial  Carotid  Femoral (don’t do)  Popliteal  Posterior tibialis  Dorsalis pedis Intro: name, patient details, consent  “Today I have been asked to examine your pulses. This will involve me feeling pulses in ur arm, neck and legs. It shouldn’t be painful. Is that ok?”  Wash hands  Ask if patient is in ANY PAIN  Role sleeves up, shorts, shoes and socks off 1. RADIAL o Rate: time for 15 seconds and x4 o Normal = 60-100bpm o Rhythm: regular, regular irregular, irregular irregular (AF) o Symmetry: feel both radial pulses together o Character: normal, collapsing pulse, slow rising pulse o ANY SHOULDER PAIN, raise wrist sharply above shoulder level while palpating pulse o Looks for a collapsing pulse = aortic incompetence2. BRACHIAL o Both sides separately 3. CAROTID o Volume: normal/good, low, high (bounding pulse) o Character: slow rising pulse = aortic stenosis o Bruits: listen with stethoscope o *don’t feel both at the same time* - both sides separately 4. FEMORAL o DON’T DO, just mention you would feel it 5. POPLITEAL o Both sides separately 6. POSTERIOR TIBIALIS o Both sides separately 7. DORSALIS PEDIS o Both sides separatelyREMEMBER  Must feel pulses on both sides of the body  Take your time to feel each  Verbalise what each pulse is called  If you can’t feel one be honest – can never feel popliteal!  Thank patient at the end  Wash hands afterHand exam  Inspect  Palpate  Move  Special tests  Phalen’s test  Tinel’s test Intro: name, patient details, consent  “Today I have been asked to examine your hands. This will involve me firstly having a look then I will have a feel and get you to do a few movements. Is that ok?”  Wash hands  Ask if patient is in ANY PAIN  Role sleeves up, give a pillow INSPECT  Dorsal aspect: bruising, muscle wasting, Herbendens nodes, Bouchard's nodes finger clubbing, nail pitting, nicotine staining  TURN HANDS OVER – any problems doing this  Palmar aspect: muscle wasting, scarring, bruising, palmar erythema, dupytren’s contracture  Forearm: nodules, rash Finger clubbing Herbenden’s nodes Bouchard’s nodes Nail pitting Dupytren’s contracture Palmar erythema Small muscle wasting Nicotine stainingPALPATE  Temperature @ hand, wrist and forearm  Squeeze across MCP joints  Individually palpate each PIP and DIP joint  Each hand separately  Comment on any tenderness or swelling  Look at patient for pain, and ask throughout MOVE  Active movements  Finger extension: “straighten your fingers”  Finger flexion: “make a fist”  Wrist palmar flexion : “flex your palm towards your forearm”  Wrist dorsiflexion: “flex the back of your hand towards your forearm”  Opposition of the thumb: “touch your thumb to your little finger”  Passive movements  Wrist palmar flexion and dorsiflexionSPECIAL TESTS  Power grip: “squeeze my finger with your hand”  Pincer grip:“pinch my finger with your finger and thumb” Assess for carpal tunnel syndrome – will experience tingling and numbness  Phalen’s test  Hold back of hands against each other for 1 minute  Tinel’s test  Repeatedly tap over the median nerve entrance to wrist  Thank patient  Wash handsOSCE TIPs  ALWAYS wash your hands – even if taking a history  Find a group to practice with  1-2 hours everyday  Use the DOCS  https://www.med.qub.ac.uk/Portal/cskills/students/DOCS.aspx  Relax – the stations will be exactly how you have practice them  Talk to the patient throughout and explain what you are doingAny questions?