Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

The Peripheral Arterial DiseaseExamination DR AMY ROSS (FY2)OSCE EXAMINATION– what is expected Important aspects from history Recapon upper & lower limb anatomy GENERAL INSPECTION PALPATION ABPI Leriche Syndrome Beurger’s test Beurger’s disease Compartment Syndrome Understand Anatomy of upper and lower limb arterial systems Understand the difference between Intermittent Claudication/Critical limb ischaemia Know how to use the doppler! Understand ABPI and what each OSCE: hints score indicates… and tips Beurger’s test Understand the difference between Arterial/Venous and Diabetic ulcers Compartment syndromeOSCE CHECK LIST - https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist- Peripheral-Vascular-Examination.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explainwhat the examination will involve 5. Gain consent 6. Position the patient on the bed, with the head of the bed at45°. Important - ** ask patient if they are in any pain prior to examining **Important Q to gather from hx.. Claudicatiowalk before pain beginse they able to Painwhen lying flat (loss of gravity to assist flow) ?Pain at rest when sitting Any previous operations or any amputations? ?any familyhistory LIFESTYLE – Smoking/Diet/Diabetes Erectile Dysfunction EFFECTS ON ACTIVITIES OF DAILY LIVINGGeneral InspectionGeneral Inspection General Inspection– Is the foot Is there any cyanotic or well mobility aids? ?Xanthelasmata Amputation perfused? ? Tarstaining Cold/Warm to hands touch? Any previous scarring from ? Any ulcers Gangrene Medications – check in or previous surgery? between necrosis?? toes!Medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus àTemperature and Capillary Refill IMPORTANT to check for in peripheral arterial disease examination Good indicators of perfusion (as discussed in previous sessions) How do you test for both? Could comment you would check Blood pressure to determine if any differences in the pulse pressure…What features do you comment on when taking the pulse? Rate Rhythm Character Volume SymmetryWhat are the causes of radioradio delay?Subclavian artery stenosis (e.g. compression by a cervical rib) Aortic Dissection CorotidPulse Be confident in knowing anatomical landmarks – carotid pulse located between the larynx and the anterior border of sternocleidomastoid muscleAuscultation & Palpation Rule out the presence of a bruit. (Carotid stenosis) risk of dislodging a carotid plaque and causing an ischaemic stroke. Be aware may be radiating cardiac murmure.g. aortic stenosis). If no bruits identified: carotid pulse palpation: Assess the character (e.g. slow-rising, thready) and volume of the pulse.Abdomen- ? AAA Any obvious pulsation? Could palpate to see if could feel any expansile pulsating mass Auscultation to area to listen for turbulent blood flow: Aortic bruits: 1-2 cm superior to the umbilicus Renalbruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side (renal artery stenosis). Lower limb TIP: flex leg slightly to feelforpopliteal pulse..What are the pulses in the lower limb following popliteal?Lower limbDorsalis PedisPosterior tibial arteryFemoral artery located at mid-inguinal point (medial to deep ring) Inguinal ligament Representsthe free lower border of the external oblique which rolls inwards as an aponeurosis (flattened tendon). Inner surface acts as origin of lowerfibres of the internal oblique, which arch over the spermatic cord, forming the roof of the inguinal canal and inserting into the pubic crest as the conjoint tendon (jointly with transversalis). Level of midpoint of ligament is deep ring (defect in posterior abdo wall– transversalis fascia) through which Deep ring spermatic cord emerges VS the mid point of line from located here ASIS to pubic symphysis is landmark of femoral artery. What things may affect measurements? ABPI INDICATION ABPI Index Calcified vessels often cause this >1.2 (Diabetic). (further assessments such as duplex ultrasound and angiography). 1.0-1.2 Normal result Mild arterial disease: typical 0.8-0.9 presenting features include mild claudication. Moderate arterial disease: typical 0.5-0.79 presenting features include severe claudication. Severe arterial disease: typical presenting features include rest pain, <0.5 ulceration and gangrene. This is also known as critical limb ischaemia. 1. Applies gravity to oppose blood flow Beurger’ stest 2. Used to assess the adequacy of the arterial supply to theleg. 1 2 3 the bottom of bed, elevate patient’s feet to 45the colour of the limbs: their legs down over the side of the bed:g degrees slowly for 1-2 minutes. Pallor à peripheral arterial pressure is unable to Gravity should help reperfusion of the leg, overcome the effects of gravity, resulting in loss of resulting in the return of colour to the patient’s limb perfusion. limb. If a limb develops pallor, note at what angle this The leg will initially turn a bluish colour occurs (e.g. 25 degrees), this is known asBuerger’s (passage of deoxygenated blood through the angle. ischaemic tissue). Healthy à entire leg should remain pink, even at Then the leg becomes red due to reactive an angle of 90 degrees. hyperaemia(secondary to post-hypoxic arteriolar dilatation (driven by anaerobic Angle <20 degreesà severe limb ischaemia. metabolic waste products)). Beurger’ sdisease - Also known asThromboangitis Obliterans - Peripheral Vasculardisease of smokers Acute inflammation involving small to medium sized arteries in extremities --> thombus formation--> obliterates lumen --> ischaemia and gangrene Young, middle-aged males, heavy smokers (age 25-40) Intermittent claudication in feet or hands Painful ulceration of digits LericheSyndrome BUTTOCK, THIGH & CALF PAIN + ERECTILE DYSFUNCTION = LERICHE SYNDROME Bilateral common iliac stenosis Claudication / Absent femoral pulses / Erectile dysfunction TriadManagement 1. Supervised exercise 2. Best medical treatment (anti-platelet/statin/blood pressure & diabetes medication) 3. Endovascular treatments (angioplasty +/- stent) 4. Surgical reconstruction 5. Amputation Further Investigations Blood pressure Ankle Brachial Pressure Index Measurement Upper and Lower limb neurological examination Cardiovascular examinationCase example 74 year old gentleman admitted following being run over by his tractor.. stop the tractor but wheel hit into his legst level ground, tractor started rolling off and ran to CT Panscan - 4x10x17cm contained haematoma on the anteriorolateral aspect of thigh Nil other injuries What would you wantto consider when examining a patient who presented like this? Compartment Syndrome flow to the area à potentially damaging the muscles and nearby nerves Causes: a broken bone or a crush injury – this is the most common cause a plaster cast or tight bandage being applied to a limb before it has stopped swelling Burns - can cause the skin to become scarred and tight Surgery to repair a damaged or blocked blood vessel (once bloodis able to flow back into a muscle, it can lead to swelling)Practice Q 1. What is the location of the dorsalis pedis pulse to the extensor hallicus longus tendon? A Medial B Lateral 2. Is the posterior tibial pulse located anteriorly or posteriorly to the medial malleolus? A Anterior B Posterior3. Calculate the ABPI for the R foot.. What does this indicate…? Answer Right brachial artery: 120 mmHg A. 0.64 Left brachial artery: 125 mmHg B. 0.4 Right dorsalis pedis: 80 mmHg C. 0.94 Right posterior tibial artery: 75 mmHg D. 1.2Answer Right brachial artery: 120 mmHg Left brachial artery: 125 mmHg Right dorsalis pedis: 80 mmHg 120 125 Right posterior tibial artery: 75 mmHg mmHg mmHg 80 mmHg 75 mmHg Right ABPI = 80/125 = 0.64 (moderate arterial disease)4. What are the 6 P’s A – painless, pallor, poikilothermia, pulselessness, paraesthesia, paralysis B – pain, pallor, pulselessness, paraesthesia, protrusion, paralysis C - pain, pallor, poikilothermia, pulselessness, paraesthesia, paralysisAnswer : CThank you! Please complete feedback..References Leriche syndrome. Hiroki Matsuura, Hiroyuki Honda. Cleveland Clinic Journal of Medicine Sep 2021, 88 (9) 482-483; DOI: 10.3949/ccjm.88a.20179 https://geekymedics.com/ankle-brachial-pressure-index-abpi-measurement-osce-guide/ https://geekymedics.com/peripheral-vascular-examination/ https://teachmeanatomy.info/upper-limb/vessels/arteries/