Clinical Examination Guide

Arterial Examination

Components of the examination

• Introduction and general inspection • Upper limb - inspection, palpation • Head and neck - inspection, palpation, auscultation • Torso - inspection, palpation, auscultation • Lower limb - inspection, palpation, auscultation • Special Tests - Buerger’s test, ABPI

Introduction and general inspection

• Gel hands - Night pain • Introduce yourself, confirm patient ID - Symptoms of numbness or paraesthesia • Explain examination and the need to remove - Infection and tissue loss clothing down to their underwear on the lower - Risk factors for cardiovascular and peripheral body vascular disease

• In taking a full history, ensure the following • Ask if they are in any pain currently questions have been asked with regards to pain • Perform general inspection of the patient – noting, suspected to be due to peripheral arterial disease for example, amputation (PAD) • Look around the consultation area for pointers - Timecourse of any leg pain towards cardiovascular or peripheral vascular - Short distance claudication i.e. pain in the legs disease (PVD), e.g. medication such as GTN/ anti- brought on by walking, relieved by rest hypertensives etc., walking aids, cigarettes - Rest pain

Upper limb

Inspection Examine hands and fingers for: • Colour: Pale? Cyanosis? • Hair distribution - chronic arterial disease may inhibit hair growth • Tobacco staining

Document Owner: Clinical Skills/SR Last Updated: Sept 2018 • Clinical signs of dyslipidaemia e.g. tendon xanthoma - these are subcutaneous (usually mobile) papules or nodules that are related to tendons and ligaments, most commonly on the dorsal aspect of the fingers, feet and Achilles tendon. Formed by localised accumulation of lipid-laden foam cells, they indicate severe hypercholesterolaemia. • Skin inflammation, ulceration, tissue loss +/- infection

Palpation • Assess temperature with the dorsum of your hands, bilaterally, from distal to proximal • Perfusion - Assess capillary refill time at the fingers • Bilateral radial and brachial pulses - Note presence and character of each pulse - Note any irregular rhythm (atrial fibrillation is a risk factor for embolic disease) - Assess for radio-radial delay (delay of the left radial pulse compared to the right radial pulse, possibly due to coarctation of the aorta proximal to the left subclavian artery. Note if coarctation of the aorta occurs distal to the left subclavian artery, radial pulses will be synchronous but radio-femoral delay will occur). • Bilateral blood pressure (BP >10mmHg difference in each arm can be a sign of peripheral vascular disease, aortic dissection or coarctation of the aorta)

Head & Neck

Inspection Palpation • Inspect eyes and surrounding skin for clinical signs • Palpate carotid pulses (one at a time!) of dyslipidaemia - Xanthelasma – soft, yellow, subcutaneous Auscultation papules or plaques in the periorbital region • Auscultate the carotids for bruit formed by an accumulation of lipid-containing - Use the bell of the stethoscope macrophages - Normal flow and complete obstruction is silent; - Corneal arcus – a grey opaque annular line that bruit (swooshing sound) suggests partial surrounds the corneal margin, separated from obstruction it by an area of clear cornea. Caused by lipid deposition in the peripheral corneal stroma • Carotid endarterectomy scars

Torso

Inspection • Midline sternotomy scar (? open aneurysm repair, ? coronary artery bypass graft)

Palpation • Examine for abdominal aortic aneurysm - Position the fingers of both hands on either side of the mid-line, midway between the xiphisternum and the umbilicus - An aneurysm is expansible and will push up and out towards your fingers (note can be difficult to discern an aneurysm from a normal pulsatile aorta) - It is quite usual to feel (and see) a pulsatile, but non-expansible aorta in a slim patient - If you suspect an aneurysm, try to assess the diameter but do not press hard

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Auscultation • Auscultate the aorta and renal arteries for any bruit

Lower limb

Inspection Examine legs, feet and toes for: • Colour: Pale? Cyanosis? • Dressings • Trophic changes, e.g. hair loss, shiny skin, muscle wasting • Amputation (count toes!) • Other evidence of previous vascular procedures (note scars of catheterisation may be tiny) • Skin inflammation, ulceration, tissue loss +/- infection, checking heels and between toes

- Arterial ulcers tend to be well-demarcated, punched out, painful ulcers over pressure points such as the heel, tips of toes, in-between toes and lateral malleolus - Venous ulcers - more common, typically shallow, painless ulcers and in the “gaiter region” (ankle to knee). Healing venous ulcers have sloping edges. The base of the ulcer may have areas of granulation tissue and surrounding skin may be inflamed with evidence of pooled blood (stasis dermatitis) or cellulitis - Necrobiosis Lipoidica - a granulomatous inflammatory condition associated with dermal collagen degeneration and microangiopathy, it presents as slowly developing, yellowish brown/ red, round, oval or irregular shaped plaques with a pale, shiny, thin, telangiectasia centre that occurs most commonly on the anterolateral surface of the lower leg. Can be associated with diabetes mellitus - Gangrene (wet/dry/infected)

(See appendix for images)

Palpation • Assess temperature using dorsum of hands and going proximally from toes to legs • Note bilateral capillary refill time of the toes • Note presence and character of each pulse bilaterally - Femoral (midway between ASIS and pubic symphysis) - Popliteal (deep in the midline in the popliteal fossa, hook the hamstring tendons out of the way with the index fingers and use the other three fingers to feel for the pulse. Press deeply and “roll” fingers from side to side. Difficult to palpate - Posterior tibial (posterior to the medial malleolus) - Dorsalis pedis (cleft between the first two metatarsals, just lateral to the extensor hallucis longus)

Auscultation • Auscultate bruits bilaterally - Iliac – Inferior and lateral to umbilicus - Femoral – over femoral pulse - Popliteal - Over any other swellings revealed in your examination

Lower limb arteries (source: http://www.yoursurgery.com/ProcedureDetails.cfm?BR=1&Proc=33) Page 3 of 5

Special tests

Buerger’s test: This test assesses the adequacy of arterial supply to the leg.

• With the patient supine, passively raise the leg until the limb becomes pale noting the angle (Buerger’s angle); or to approximately 700 and hold there for 30s • Sit the patient up and lower the leg over the edge of the bed at 900 and measure the time taken for the colour to return to normal. Observe for cyanosis and reactive hyperaemia

• In a healthy limb, there will be no change in colour of the foot in elevation even to 900 • If the circulation is inadequate, the veins will empty on elevation and the foot will go pale due to inadequate arterial supply (the effects of gravity > arterial pressure). The collapsed veins may have an indented appearance (venous guttering) • When you then lower the legs off the bed, the veins will slowly fill again as the arterial supply returns and the foot will go red. This redness is called “reactive hyperaemia” – the dilation of the blood vessels that follows a period of impaired circulation

Ankle-Brachial Pressure Index (ABPI) This test measures the pressure gradient for central-peripheral arterial pressure A doppler probe is used to measure the blood pressure in the ankle and arm. The ratio of these two values (ankle systolic blood pressure/ brachial systolic blood pressure) quantifies the gradient for central-peripheral arterial pressure indicating the severity of vascular disease.

• Position the patient lying flat • Place a blood pressure cuff on the upper arm in the normal position • Palpate for the brachial or radial pulse and apply ultrasound coupling gel • Place the ultrasound probe at 45-600 over the pulse • Proceed to measure the systolic pressure in the upper limb, using the ultrasound to listen for the first Korotkoff sound • Remove and replace the cuff over the lower calf • Palpate Posterior Tibial and Dorsalis Pedis pulses. • Measure systolic pressure in both arteries with Doppler in the same way • Using the higher of the two lower limb systolic measurements calculate ABPI as

Highest ankle systolic pressure Brachial systolic pressure

- Normal: 0.9 - 1.1 - Arterial insufficiency: 0.4 - 0.9 - Critical ischaemia: < 0.4 - Ratio >1.3 may indicate diabetic calcification

Conclusion

• Thank the patient, ask them to get dressed, report/record findings • Consider examination of the peripheral venous system, cardiovascular system and neurological examination of the lower limb affected limb

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Appendix

Tendon xanthoma (source: http://www.pcds.org.uk/clinical- guidance/xanthomata)

Xanthelasma LEFT (source: http://www.pcds.org.uk/clinical- guidance/xanthomata

Corneal arcus RIGHT (source: https://webeye.ophth.uiowa.edu/eyef orum/atlas/pages/Arcus/index.htm)

Arterial Ulcer LEFT (source:https://www.vascularsociety. org.uk/patients/conditions/12/arterial _ulcer)

Venous ulcer RIGHT (source: https://www.intechopen.com/books/ wound-healing-new-insights-into- ancient-challenges/venous-leg- ulceration

Necrobiosis Lipoidica

(Source: https://www.dermnetnz.org/topics/n ecrobiosis-lipoidica/)

Toe gangrene secondary to Buerger's disease (source: http://www.angiologist.com/arterial- disease/buergers-disease)

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