Contents
Introduction
- introduce yourself
- wash your hands
- check you’ve got the right patient
Inspection
- Is the patient in any pain?
- Check around the bed
- Mobility aids
- O2
- Cigarettes
- Medication
- Look for any general signs – e.g. heart failure, cyanosis, pallor
Hands
Look for:
- Tar staining
- Palmar xanthomas
- Capillary return – Press for at least 2-3 seconds – then check the return appears within 2 seconds
- Radial pulse – comment on the rate, rhythm and character. Also check for radio-radial delay – this is a sign of co-arctation of the aorta.
- Do the blood pressure in BOTH arms
Face
- Eyes – look for xanthelasma, arcus and conjunctival pallor
- Mouth – look for central cyanosis and angular stomatitis
- Caroitd pulse – check it and comment on the character!
Abdomen
- Look for obvious pulsations and masses
- Look for scars
- Check the AA – is it pulsatile (normal) or expansile (abnormal). The aorta bifurcates at approximately the level of the umbilicus
Leg inspection
ASK! If they have any tenderness anywhere
Compare left to right! Any signs of:
Compare left to right! Any signs of:
- Swelling
- Discoloration
- Scars
- Dressings
- Pallor
- Missing hair / nails / toes
- Ulcers
- Dry skin
- Just have a good look and feel of the legs and toes. Make sure you look between the toes and lift up the feet.
- Compare the temperature with the back of your hand – do this at 3 separate places on each leg
Leg palpation
Good idea to work distal to proximal
- Temperature – compare both legs using the back of your hand. Compare in several different places
- Sensation – ask the patient to close their eyes, and then touch them in a couple of different places on their feet. Ask them to say where/when they feel it
- Capillary refill – same as for the hands
- Pulses – check that these are normal / absent / reduced – comment on what you find
- Dorsalis pedis
- Posterior tibial
- Popliteal – take the weight of the patients legt with both hands and feel into the popliteal fossa
- Femoral
Berger’s test – this is useful for those with severe arterial disease.
- Lift up the legs for 30s to 1 min, and see if they go pale
- If they do, then ask the patient to then sit up and drop the leg over the side of the bench. If the leg then turns red/purple then this is a positive test and the patients has reflex hyperaemia which is present when there is poor peripheral circulation
- Reflex hyperaemia occurs when there is dilation of the peripheral blood vessels when the leg is raised in response to the fall in bp. Then when the leg is lowered, the massively dilated blood vessels suddenly fill causing the leg to go a red/purple colour
Auscultation
Listen for bruits:
- Renal bruit
- Femoral bruit
- Aortic bruit
- Carotid bruit
To finish
- Thank the patient
- Aks if they have any questions
- Allow them to re-dress in private
- Mention any further possible tests:
- ABPI – ankle-brachial pressure index – this is the ratio of the blood pressure in the lower legs to the blood pressure in the arms:
The higher reading from left/right arm is used. In healthy individuals, the ABPI is >1.0, but in cases of intermittent claudication it can be 0.5-0.9. in critical limb ischemia, it is <0.5.
- Method – you use a BP cuff, and sphygmomanometer, and a Doppler scanner (sometimes called a Doppler wand). After placing the cuff over the artery, you use the Doppler Wand to asses when the pulse is present (in a similar way you use the stethoscope when taking a standard BP), thus the wand is distal to the cuff. Measure the pressure in both the ankle and the arm using this method.