Peripheral Vascular Examination (arterial) – 5 min station

Communication with patient

- Introduction and orientation (name, role and confirms patient's agreement)

- Rapport (shows interest, respect and concern, appropriate body language)

- Communicates with patient appropriately during examination (explains what

he/she is doing, gains co-operation)

- Examines the patients in a professional manner (gentle, watches for pain,

maintains dignity and privacy)

Examination process

- Appropriately exposes the patient and positions the patient for different parts

of the examination. Starts with patient at 45 degrees

- Inspects hands, arms, neck, chest, abdomen and limbs for stigmata of arterial

disease (pallor, rubor, ischemic ulcers, gangrene, visible pulsations, nicotine

staining, etc.)

- Checks the radial pulses commenting on rate and rhythm

- Checks the brachial pulses

- Asks for patient’s brachial blood pressure

- Palpates for parotid pulses and listens for bruits

- Examines the heart - apex beat, right ventricular heave, auscultation

- Lays patient flat and palpates abdomen for aortic aneurysm. If enlarged

measures this and comments on size

- Uses stethoscope to auscultate for aortic and iliac bruits

- Palpates femoral pulses and listens for bruits

- Palpates popliteal pulses - knees flexed to 135 degrees

- Palpates the dorsalis pedis and posterior tibial pulses

- Performs Buerger’s test

- Asks for patient’s Doppler ankle pressures

Presentation

- Closure (thanks patient, eaves patient comfortable)

- Candidate presents summary in a fluent, logical manner

- Candidate makes a reasonable attempt at a diagnosis

- Examiner asks for clinical reasoning, which led to diagnosis

- Logical deduction from symptoms and signs

- Candidate presents further investigations

Peripheral Vascular Examination (venous; lower limb)

Communication with patient

- Introduction and orientation (name, role and confirms patient's agreement)

- Rapport (shows interest, respect and concern, appropriate body language)

- Communicates with patient appropriately during examination (explains what

he/she is doing, gains co-operation)

- Examines the patients in a professional manner (gentle, watches for pain,

maintains dignity and privacy)

Examination process

- Appropriately exposes the patient and positions the patient for different parts

of the examination. Starts with patient at 45 degrees

- Inspects the legs for stigmata of venous disease - varicose veins, leg oedema,

skin staining in the gaiter area, lipodermatosclerosis, venous ulceration,

cellulites, etc.

- Palpates the leg for tenderness and pitting oedema

- Inspects the patient standing up

- Checks for presence of varicose veins in LSV territory, SSV territory and

abnormal distributions e.g. lateral side of leg

- Comments on presence of varicose veins, size and distribution

- Performs tap test - percussion of veins

- Locates saphenofemoral junction and ask patient to cough - comments on

palpable thrill

- Asks the patient to lie flat

- Performs Trendelenburg and tourniquet test for varicose veins

- If necessary repeats test placing the tourniquet in the above knee and below

knee positions

Presentation

- Closure (thanks patient, eaves patient comfortable)

- Candidate presents key findings

- Candidate presents summary in a fluent, logical manner

- Candidate makes a reasonable attempt at a diagnosis

- Examiner asks for clinical reasoning, which led to diagnosis

- Logical deduction from symptoms and signs

- Candidate presents further investigations

Varicose Veins Examination

Quick reminder of anatomy:

- major superficial veins: long and short saphenous

- The superficial system connects to deep system for drainage via perforator veins.

- If valves are broken/incompetent, then you get backflow.

Communication with patient

- Introduces self, name, role and purpose of examination (+ hand hygiene)

- Ensures patient comfortable, prepared and happy to proceed

- Explains process and examination to the patient as they proceed in a professional and considerate

manner

- Thanks patient and explains that examination is complete when finished (+ hand hygiene)

Examination

- Ask if patient is in pain before starting

- Inspect legs while patient is standing for:

distribution of veins, ulcers, eczema, venous stars, lipodermatosclerosis, atrophy blanches, pitting

oedema, scars (if you find oedema, check JVP)

- Palpate for temperature, tenderness and hardness with back of hand. Do not forget gaiter area

= lower third of the medial aspect of the leg, immediately above the medial malleolus

- Can do direction test where one empties a short section of a vein, by sliding a finger across, then

compress vein at two sites and let go of the higher site, watch if it refills. If yes => incompetence.

- Feel for leg pulses: Femoral. Popliteal, dorsalis pedis, tibialis posterior, delays?

- Test cough impulse: find saphenofemoral junction (2-4cm inferolateral to pubic tubercle, or

medial of 1/2way point between ASIS and pubic tubercle) and ask patient to cough. If impulse felt

(text + presence of saphena varix).

- The 'tap test': put finger lightly onto saphenofemoral junction, then tap on varicose vein lower

down the leg. If they are in continuity (i.e.: the valves are incompetent) then you will feel thrilling

from the vein to the junction (thrills are normally interrupted by competent valves, if not then

tapping sends a shock wave up the vein that is palpable).

- Trendelenburg test (used to assess the competence of SFJ):

o lie the patient down, elevate the leg and drain venous blood from the varicose vein

o place two fingers on the SFJ

o ask patient to stand, keeping fingers in place, then release fingers

o If the veins do not refill until the pressure is removed = “can control refill” ! SFJ is

incompetent

o If the veins do refill ! SFJ may or may not be incompetent, presence of distal

incompetent perforators

- Tourniquet test:

- ask patient to lie down and lift up leg, draining venous blood from the varicose vein

- apply a tourniquet mid-thigh, and later below the knee

- ask patient to stand up

- look for refill of the varicose vein – normal is a few seconds

- Auscultate over a large group of veins (if present may indicate an underlying arteriovenous

malformation)

Presentation

- Follows a fluent process which appears professional (allowing for variation in methods taught or

learnt)

- To finish examination:

Doppler ultrasound, examine the abdomen for masses to ascertain whether the varicose veins are

primary or secondary, complete a peripheral vascular exam for arterial supply of the lower limb,

including ABPI, perform Perthes Test:

o Empty the vein as above, place a tourniquet around the thigh, stand the patient up.

o Ask them to rapidly stand up and down on their toes – filling of the veins indicated deep

venous incompetence. This is a painful and rarely used test.

- Presents findings in a clear and logical manner. Makes a reasonable attempt at diagnosis when

questioned

- if varicose vein present, which vein does it come from?

GALS = Gait, Arms, Legs, Spine

Examined in the order:

1. gait

2. spine

3. arms

4. legs

- patient only wears underwear

- start with questions: o any pain or stiffness?

o Where?

o Ever had gout?

o Difficulty dressing him/herself?

o Difficulty with stairs?

1. Gait - inspect

- symmetry

- coordination

- smoothness of movement

- use of aids

- turning ! balance

- also inspect popliteal fossa for swelling

2. Spine

- inspect spine for

o from front: symmetry

o from back: scoliosis (muscle bulk, iliac crests)

o from side: curvature – lordosis, kyphosis

- flexion: place finger on two lumbar vertebrae and ask patient to touch toes

- lat flexion: run arms down side of leg

- cervical spine:

o lat cervical flexion, ask patient to touch shoulder with ear

o turn head

o look up and down

3. Arms

- inspect hands for swelling or deformity from both sides

- squeeze on metacarpals

- movement: grip strength (fist), precision / coordination (pincer)

- prayer and inverse prayer

- extend elbows

- put hands behind head, touch small of the back (above T10)

- even extend above head (ask for pain)

4. Legs

- Get patient to lie on bench

- Inspect knee for

o Swelling, deformity (varus/valgus)

o Quadriceps muscle bulk

o Effusion

- Movement: extension / flexion (also flexes hip)

- In flexed position test hip int and ext rotation

- Inspect feet, check for callouses

- Movement of feet: plantar and dorsiflexion, inversion, eversion

- Squeeze metatarsal joints

Groin Examination

LANDMARKS REMINDER

• Mid-inguinal point: ! between ASIS and pubic symphysis

o Location of FEMORAL ATERY

• Midpoint of inguinal ligament: 1/3 between ASIS and pubic tubercle

o Location of DEEP INGUINAL ring and indirect inguinal hernia

o Direct hernia will be medial to this!

• Femoral hernia emerges from femoral canal below and lateral to pubic tubercle

Communication with patient

- Introduces self, name, role and purpose of examination

- Ensures patient comfortable, prepared and happy to proceed

- Explains process and examination to the patient as they proceed in a professional and

considerate manner

- Thanks patient and explains that examination is complete when finished

Examination process

- Follows a fluent process which appears professional (allowing for variation in methods

taught or learnt)

- Ask if any pain, then inspect for:

- swellings on either side of the groin

- asymmetries/swellings within the scrotum

- groin creases for sinuses/fistulae/erythema/obvious swellings

- scars

• Ask patient to cough, and watch for hernia protrusion

• Palpate:

- Midpoint of the inguinal ligament, 1 finger on deep ring, 1 on inguinal ligament

(superficial ring) – and ask patient to cough

- same position but with pressure on deep ring – ask patient to cough again

- for inguinal herniae: press firmly over the internal inguinal ring, holding the

hernia reduced, then ask the patient to cough:

o Is it controlled?

! Yes = INDIRECT Inguinal.

! No = DIRECT Inguinal.

- release the pressure and let the patient cough again. Hernia will re-appear.

- If mass ascertain the following: position, size, shape, temperature and tenderness

• Ask the patient to reduce the hernia him/herself. If unable to, try to reduce it yourself,

and ask to put pressure on side of hernia to hold it in. Stand the patient up and ask them

to cough in order to check for presence of another hernia on the other side.

• Feel for superficial inguinal lymph nodes. The groin lymph nodes lie below the inguinal

ligament.

• Feel for the femoral pulse. Femoral artery aneurysm: main feature is expansile swelling

not just pulsatility.

• Feel for the femoral canal by asking the patient to cough again. Femoral hernia

detectable? If so, reduce and ask to cough again.

• Listen to the femoral artery (in case of aneurysm)

Presentation

- Presents findings in a clear and logical manner. Makes a reasonable attempt at diagnosis

when questioned

To finish examination: perform abdominal examination, examine external genitalia and scrotum

Thyroid Examination

Communication with patient

- Introduction and orientation (name, role and confirms patient's agreement)

- Rapport (shows interest, respect and concern, appropriate body language)

- Communicates with patient appropriately during examination (explains what

he/she is doing, gains co-operation)

- Examines the patients in a professional manner (gentle, watches for pain,

maintains dignity and privacy)

Examination process

- Ensures patient seated in good light, with access to examine from behind and

appropriate exposure of the neck

- Observes patient from front commenting on any scars, obvious lumps/swellings

- Asks patient to swallow (with drink if necessary) to check upward movement of

thyroid gland and to ascertain whether any visible lumps/swelling ascend with the

thyroid

- Examines thyroid gland from behind, commenting on size, symmetry and

consistency, checks for movement with swallowing

- Examines neck for lymphadenopathy

- Auscultates gland to listen for bruit

- Checks for retrosternal extension by percussing over upper sternum

- Checks for evidence of lid retraction/lid lag (present in thyrotoxicosis of any

cause) and one or more of exophthalmos / ophthalmoplegia / periorbital oedema /

chemosis (which are specific to Graves’ disease)

- Examines hand to look for tremor and sweating

- Checks radial pulse and comments on rate and rhythm

- Checks for pretibial myxoedema

- Checks for slow relaxation of reflexes

Presentation

- Closure (thanks patient, leaves patient comfortable)

- Candidate presents key findings

- Candidate presents summary in a fluent, logical manner

- Candidate makes a reasonable attempt at a diagnosis

- Examiner asks for clinical reasoning, which led to diagnosis

- Logical deduction from symptoms and signs

- Candidate presents further investigations

Breast Examination

Communication with patient

- Introduces self, name, role and purpose of examination

- Ensures patient comfortable, prepared and happy to proceed

- Explains process and examination to the patient as they proceed in a professional

and considerate manner

- Thanks patient and explains that examination is complete when finished

Examination process

- Follows a fluent process which appears professional (allowing for variation in

methods taught or learnt)

- Inspect general appearance of patient:

Cachexia, pallor, shortness of breath

- Inspect breast with patient sitting up, then arms behind head, then arms on the

side for:

Swellings, asymmetries, pitting, peau d'orange, prominent veins, dimpling,

puckering, scars, redness, nipple retraction

- Inspect the supraclavicular area and axillae for swollen nodes, veins and muscle

wasting. Also look for any past signs of breast cancer, e.g.: mastectomy, scars,

hair loss, radiation burns, lymphoedema

- Lay patient at 45 degrees with hand resting behind head, and ask if any pain, or if

they noticed any lumps.

- Palpate (outwards in with flat of fingers) in the four quadrants and the nipple

areolar complex (NAC). Specifically check for discharge.

- If lump felt describe:

Tenderness, site, size, shape, surface, edges, consistency, colour, contour,

pulsatility, fluctuation, temperature, reducibility, mobility , tethering

If there is a lump, ask the patient to push forward against your hand and assess if

it is attached to underlying muscle

- Palpate the axilla, by asking patient to lift arm up, place hand in axilla, lift arm

down to rest on yours, then roll fingers down axilla 4 times. (examine the left

axilla with the left hand and vice versa). If you feel a lump, feel if it is fixed or

not.

- Palpate the supraclavicular nodes.

Presentation

- Presents findings in a clear and logical manner. Makes a reasonable attempt at

diagnosis when questioned

To finish examination:

- examine the lungs, neurological system, spine and abdomen (if there was a lump)