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VASCULAR EXAM & HISTORIES Laulwa Al Salloum, 4 year medical student 2367445A@student.gla.ac.ukWHA T WE’RE COVERING VASCULAR HISTORY PERIPHERAL VASCULAR CLINICAL REASONING EXAMEXAMPLE INSTRUCTIONSCLINICAL EXAMINATION You are an FY2 in Emergency Medicine. This patient has been admitted with leg pain. • History Taking (14 marks): take a history of the presenting complaint from the patient • Examination (10 marks): perform a peripheral vascular exam on this patient • Patient Consultation (6 marks): marks awarded for appropriate and effective patient interactionVASCULAR HISTORIES YOUR HISTORY WORKFLOW Introduction PC HPC WINDEC (establish why (WADIP - the bulk Systemic enquiry they’re there) of your marks) WADIP ICE When, Acute/chronic, Duration, Intensity, Summary Progression PMH + PSH SH FH DH (ask relevant Qs) THE REST OF YOUR HISTORY Presenting complaint – next slides Drug History: • Medications they’re taking + if anything over History of presenting complaint the counter • Bulk of your marks • Allergies, allergies, allergies + what happens • A framework is important • WADIP: When, Acute/chronic, Duration, Intensity, Family History Progression • Apply SOCRATES (it helps) • Any family history of endocrine conditions • Exacerbating / Relieving factors • If diabetes, consider autoimmune links • Use this time to explore your differentials • If malignancy, ask about cancer (I always ask this) Past medical history • Has this happened before? Social History • Habits = Smoking, alcohol, recreational drugs • Ask about surgical history – don’t forget this • (patients often don’t think of diabetes, HTN, cholesterol – • Lifestyle = Impact on their life, Mobilizing?, ask directly Housing, Diet THE REST OF YOUR HISTORY Systems Review • ALWAYS ALWAYS ask your red flags • Fever • Weight loss • Nausea • Night sweats • Work head to toe and apply what’s applicable • GI: bowels, abdominal discomfort • GU: urinary habits, blood in urine, menstrual cycle • Neuro: dizziness, visual changes, changes in sensation, headaches • If relevant, ask about pregnancy and sexual activityLEG PAIN PRESENTING COMPLAINT – focussed • Establish why they’re there • SOCRATES • Where is the pain? Calf (DDx = DVT, claudication, PAD, trauma) Foot (DDx = PAD, Nerve palsy, etc.) • When did it start? (Suddenly and severe = DVT, slow progressing = CLI) • What does it feel like? (sharp shooting = nerve compression) • Does it travel anywhere else (nerve pain shoots down legs) • Associated symptoms – we’ll touch on this in the next slide • How long has it lasted? • Does anything make it better? Anything make it worse? (next slide) • How bad is it? Scale 1-10 HISTORY OF PRESENTING COMPLAINT • RULE OUT A DVT • Have you been breathless? • Are your calves tender to touch? • Relation to exercise • Does walking make it better? (exercise therapy commonly recommended for claudication) • Does walking make it worse? (PAD, Arthritis) Good questions to ask: • Does hanging your leg off the bed make it better/worse? • Does weightbearing make it worse? • Does leaning forward help with the pain? (tying shoes) • Have you noticed changes in your skin? Sensation? Temperature? • Have you noticed any ulcers in your skin? SYSTEMIC ENQUIRY • Red flags: Night sweats, Fever, Nausea, Weight loss • Urinary and bowel changes • Is the pain waking them up from sleep • If thinking PAD, check for signs of arterial disease • SOB, Chest pain, Easily fatigued DIFFERENTIAL DIAGNOSES OF LEG PAIN CONDITION HOW IT PRESENTS Peripheral arterial disease Rest pain; Ulceration; Consistent with walking distance Venous claudication At this level: Varicose veins Spinal stenosis Bilateral pain and weakness in buttocks and posterior leg; Better when leaning forward Knee arthritis Association with weight bearing; Longer to resolve Nerve root compression Sharp shooting; Improvement with positional changes PAST MEDICAL AND DRUG HISTORY Past medical history: • Previous medical conditions or surgery • Specifically ask about hypertension, high cholesterol and diabetes • Specifically ask if they have coronary artery disease, cerebrovascular accident (aka strokes, TIAs, etc.) Drug history: • ALLERGIES • Ask about secondary prevention drugs ( touching on this later, n) spoilers FAMILY AND SOCIAL HISTORY Family History: • History of heart disease is important to ask • History of stroke Social History: • SMOKING is a very important risk factor • Habits: Smoking, Alcohol, Recreational drugs • Lifestyle: How has it affected their ADLs; Mobility; Household; Diet; ExerciseVASCULAR EXAM TIPS FOR PVD EXAM • Think of this as your ‘pulses’ exam • Will almost always be lower limb • Make sure you know where the pulses are anatomically, examiners can tellYOUR STRUCTURE Introduction General inspection Palpation Vascularity Auscultation PULSES Sensation Buerger’s testINTRODUCTION • Wash hands • Introduce yourself • confirm Name, and • Date of birth • Explain what you’re going to do • Consent GENERAL INSPECTION A. End of bed: I. Missing limbs/digits? II. Scars indicating previous surgery B. Objects and equipment I. Mobility aids II. Medical equipment (prosthetics/dressings) C. Closer inspection I. ? WHAT DO THESE IMAGES SHOW Gangrene Venous ulcer Arterial ulcer Diabetic ulcer Pressure ulcerCLOSER INSPECTION – choose 2 or 3 to say I. Peripheral cyanosis (issue with vascularity – low SpO2 - poor perfusion) II. Peripheral pallor (poor perfusion) III. Venous ulcers (shallow, wet, irregular borders, large - MEDIAL ANKLE) IV. Arterial ulcers (deep, dry, well-defined, small – PERIPH OF LIMBS/DIGITS) V. Gangrene – look between the toes (tissue necrosis due to poor perfusion - will look red/black) VI. Diabetic ulcers – lift the foot up and look at the soles VII. Hair loss VIII.Muscle wastingPALPATION I. Temperature I. Dorsal aspect of your hand on the patient’s lower limbs (compare both sides) II. Cool and pale = poor arterial perfusion III. Hot = DVT II. Vascularity I. CRT <2s II. If upper limbs = radial pulse + radio-radial delay; Brachial pulse III. Lower limbs = work systematically (next slides) IV. Offer for radio-femoral delay III. Offer for blood pressure AUSCULTATION AND PULSES Femoral pulse • Midway between anterior superior iliac spine and pubic symphysis • Mid-inguinal point Dorsalis pedis • Lateral to extensor hallucis longus tendon over dorsum of foot • Aka space between big toe and second digit Posterior tibial • Posterior to the medial malleolus of tibia • Aka behind and below medial malleolusAUSCULTATION AND PULSES I. Auscultate BEFORE palpation – why? II. Say you would inspect and palpate abdomen I. Laterally expansile mass = AAA II. Inspect abdomen III. Auscultate for aortic and renal bruits III. Lower limbs I. Femoral pulse + Popliteal pulse (you won’t feel this, just say you’re looking for it) + Posterior tibial + Dorsalis pedis IV. For each pulse, comment on character, rate and rhythmSENSATION I. Assessing gross sensation with cotton wool I. Tell patient what normal feels like by touching their sternum first I. Ask them to close their eyes and to say yes when they feel it on their lower limbs II. MAKE SURE TO COMPARE III. Start distally, if they can feel it then you don’t need to go any further BUERGER’S TEST 1. Patient supine 2. Raise both their feet to 45 degrees for 1-2 mins (just say you would) 3. Observe the colour (healthy = pink) 1. Pallor = PAD can’t overcome gravity causing poor perfusion 2. Note the angle of the pallor = Buerger’s angle 4. Sit the patient up and hang their feet over the side of the bed – help them 1. blood) then red (reactive hyperaemia) 2. Normal would just go back to normal colourCOMPLETING THE EXAM • Wash your hands and thank the patient • Explain that the examination is now over and they can get dressed if appropriate • Summarize your findings For completion I would like to…. • Exams: Cardiovascular exam; Upper/Lower neurological exam if indicated • Investigations: ABPI, Blood pressure measurementCLINICAL REASONING CLINICAL REASONING A 50-year-old man presents to the GP complaining of pain in his calves when walking. He tells you he hasn’t noticed any changes to his skin but that the pain is there at rest. He has been smoking since he was 14 and is on Ramipril for his Hypertension. CLINICAL REASONING What is the most likely diagnosis How would you manage this patient medically? • Secondary prevention drugs • Critical limb ischaemia (peripheral arterial disease) • AKA: Atorvastatin, Aspirin/Clopidogrel (Antiplatelets) What are the next actions? • Ankle-brachial pressure index How would you manage this patient surgically? • Angioplasty +/- stent • US Doppler • Bypass graft • CTA/MRA • Amputation • Referral to vascular specialist MDT How would you advise this patient in terms of controlling risk factors? What are risk factors for peripheral arterial disease? • Smoking cessation • Smoking; Hypertension; Diabetes; Hyperlipidaemia • Regular exercise • Increasing age; Obesity; Physical inactivity • Weight reduction • Supervised exercise programme in intermittent claudication WHAT SIGNS POINT TO A MORE CHRONIC > ACUTE PICTURE? • Diminished peripheral pulses • Cold/shiny skin • Peripheral hair loss • Ulceration/gangrene or both • Remember your 6 Ps for Acute limb ischaemia • Pain • Pallor • Pulselessness • Perishingly cold • Paralysis • PoikilothermiaTHANK YOU! Laulwa Al Salloum, 4 year medical student 2367445A@student.gla.ac.uk