2. General Inspection 3.

Hands
Peripheral Arterial Disease
Examination Is the patient well at rest? ‰ Temperature
Check for clues around the bed ‰ Tar Staining
1. Introduction ‰ Mobility aids ‰ Capillary Refill
‰ O2 ‰ Tendon / Palmar xanthoma
‰ Wash Hands ‰ Cigarettes ‰ Radial Pulse (Rate, Rhythm, Character)
‰ Introduce yourself, explain & gain consent ‰ Medications eg. GTN ‰ BP in both arms
‰ Check patient ID Patient
‰ Is the exam general or focused? ‰ Age
‰ Signs of heart failure
‰ Cyanosis/Pallor
6. Leg Inspection

Comparing right to left 5. Abdomen 4. Face

INSPECTION EYES
‰ Dressings
‰ Obvious pulsatations ‰ Xanthelasma
‰ Scars
‰ Masses ‰ Corneal Arcus
‰ Discolouration
‰ Scars ‰ Conjunctival Pallor
‰ Pallor
‰ Missing hair / nails / toes
PALPATION (Ask about any pain first) MOUTH
‰ Ulcers
‰ Pulsatile mass ‰ Central Cyanosis
‰ Non-healing injuries around pressure
(Progressively deeper palpation above ‰ Angular Stomatitis
points
‰ Dry Skin the umbilicus)
‰ Expansile mass ‰ * Carotid Pulse
‰ Look in between toes and lift up feet
‰ Ask the patient to wiggle their toes (Progressively deeper palpation
(Motor dysfunction in acute ischaemia) both hands either side of the umbilicus)

9. To Finish
7. Leg Palpation ( Work distal to proximal) 8. Auscultation
‰ Temperature: Compare both legs using the back of one hand ‰ Thank patient
‰ Sensation: Get the patient to close their eyes while testing ‰Femoral ‰ Ask if they have any further
‰ Capillary refill: Squeeze both big toes for 3-5 seconds & release ‰Aortic questions
(Normal = less than or equal to 2 seconds) ‰Renal ‰ Allow them to redress in private
‰ Pulses: Normal / Absent / Reduced ‰Carotids ‰ Further tests & investigations
 Pulses
• Always Compare one side with the other
• Feel for normal, absent, reduced
Femoral – With the patient lying down. The femoral artery is located
just below the mid-point of the inguinal ligament (inguinal ligament is
located between the ASIS and pubic tubercle), press fingers here,
pointing in the direction of the patient’s head.
Popliteal – Make sure your nails are cut short! The patient should
be lying down, flex their knee to approximately 10 degrees, place
the heels of your hands just lateral to the patella, press fingers into
the midline of the popliteal fossa, tell the patient to rest all their
weight on your hands. Press deeply, this is a diffuse feeling pulse.
Posterior Tibial – 2cm posterior and 2cm below the medial
malleolus.
Dorsalis Pedis – Just lateral to tendon of the Extensor Hallucis
Longus. You can ask the patient to cock their big toe back to make
locating the pulse easier, but remember to get them to relax whilst
you actually palpate it.
Radio-femoral delay and radio-radial delay – These assess for
coarctation of the aorta.
Palpating the abdominal aorta – First establish whether a midline
pulsatile abdominal mass is present, do this by using one hand to
press progressively deeper into the midline, proximal to the
umbilicus. If a pulsatile mass is found, you need to establish
whether it is also expansile, to do this you need to press quite deeply
with both hands around the mass.
Possible Further Tests
Blood Tests
FBC (Anaemia), U&Es (renal failure), Fasting Lipid Profile, Blood
sugar (diabetes)
Buerger’s Test
Ask the patient to lie flat. Remember to ask the patient if they have
had any pain in the hip joint or legs. Raise both their legs to
approximately 45 degrees and hold them there for at least one
minute. After this time ask the patient to sit up and hang their legs
over the edge of the bed. Observe the legs and feet. In significant
PAD elevation of the legs will cause pallor as the blood drains out of
them and you may see ‘guttering’ of the superficial veins. Upon
hanging the legs over the side of the bed the skin may at first turn
bluish (as blood is deoxygenated from its passage over the
ischaemic tissue) and then flush red, due to reactive hyperaemia
from post-hypoxic vasodilation.
If Beurger’s Test is positive it implies significant PAD is present.
Ankle-Brachial Pressure Index (ABPI)
Use a hand-held Doppler and a sphygmomanometer for this. First
measure the brachial systolic BP. Then measure the ankle systolic
BP (at the most distal palpable pedal pulse).
The ratio of these two BPs is the ABPI.
e.g. Ankle BP = 90 = 0.75
Brachial BP = 120
Normal >= 1
Claudication < 0.8
Critical Ischaemia < 0.4
The trend over time may have more value than absolute values.
N.B. Some patients may have incompressible calcified arteries, in
these cases the ankle BP will be falsely elevated and therefore ABPI
will be inaccurate.
Duplex Ultrasound
A possible therapeutic intervention to assess whether angioplasty may be of
benefit.
 DVT Examination
1. Introduction 2. General Inspection 3. Leg Inspection
‰ Wash Hands! Look around the bed for: (compare both legs)
‰ Introduction ‰ Wheelchair / walking aids ‰ Redness
‰ Check pt name and ID ‰ Swelling (you would expect
‰ Explain & Gain consent Look at patient for: these in DVT)
‰ Fractures
‰ Signs of surgery and injury ‰ Varicose veins
‰ Pregnancy ‰ Ulceration
‰ GTN spray ‰ Missing digits
‰ Is patient breathless

6. Auscultation 5. Measure 4. Leg Palpation

‰ Lung bases
For any signs of PE
(reduced breath sounds heard)
‰ Use the measuring tape provided (compare both legs)
‰ Mid calf, 10cm below tibial ‰ Temperature (use back of
tuberosity hand)
‰ Compare both legs at the SAME ‰ Tenderness
point ‰ Pitting Oedema
‰ If >3cm difference ⇒ significant ‰ Pulses (refer to arterial notes)
for DVT scoring

7. To finish
‰ Thank patient
‰ Cover him up
‰ Mention investigations Things to note for OSCE discussion:

1. Possible Differentials 2. Further Investigations

• Cellulitis • Wells’ Score: if low, perform D-Dimer
• Ruptured Baker’s Cyst • Bloods (FBC, U+Es, clotting)
• Lymphoedema • Duplex Scanning (USS + Doppler)
• Compartment Syndrome • Venogram

1. Introduction
‰ Wash Hands!
‰ Introduction
‰ Check pt name and ID
‰ Explain & Gain consent
7. Investigations
‰ Bloods
‰ Hand held Doppler
‰ Duplex ultrasound
‰ Colour flow Imaging
Varicose Veins Examination
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)
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.

6. To finish 5. Special Tests

‰ Thank the patient Trendelenberg/Tourniquet Test (using a tourniquet)
‰ Cover him up if you exposed him in ‰ Purpose of this test : to determine the level of incompetency
the first place ‰ Ask patient if there is any pain in his leg before you raise it
‰ Mention any investigations you ‰ Milk the veins to drain them
might do ‰ Locate the SFJ
‰ Take a history ‰ Use a tourniquet to occlude the SFJ
‰ Check the peripheral pulses ‰ 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 Tredelenberg & Torniquet Tests
• Ask patient to lie down. • The aim is to locate the level of the incompetent
• Find the femoral pulse (midway between the ASIS and valves.
the pubic tubercle). • Lie the patient down and raise the affected leg
• The SFJ is located approximately 2cm medial and 2cm attempting to drain the blood from the varicosities.
inferior to the femoral pulse. • Using either your fingers or a tourniquet put pressure
over SFJ to occlude it.
• Ask patient to stand
2cm below and
• If varicosities do not refill immediately upon
2cm medial to
standing, it indicates the SFJ is incompetent.
femoral pulse
• 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.