#. Introduction
- Wash hands (and don PPE if needed)
- Introduce yourself (name and role)
- Confirm patient’s name and DOB
- Explain what the examination involves
- Gain consent to continue
- Ask if patient in any pain before continuing
Gather equipment
General Inspection
Clinical Signs
- General appearance and alertness
- Obvious limb amputation
Objects and Equipment
- Medical equipment - Oxygen, ECG, medications, catheters (note volume and colour), IV access
- Mobility aids
- Prosthetic limbs
- Vital sign charts
- Fluid balance charts
- Prescription
Inspection of legs, foot and toes
- Colour
- Oedema
- Ulceration, trauma, which the patient might not be complaining about due to Diabetes Mellitus neuropathy
- Varicose veins
- Missing digits
- Check in-between toes and back of legs for fungal infections/ulcers
- Trophic skins changes: hair loss, discoloured skin, dry skin, thickened nails
6 Ps of acute limb ischaemia
- Pale
- Pulseless
- Painful
- Paralysed
- Paraesthetic
- Perishingly cold
Palpation & Auscultation
Assess temperature and sensation
- Using back of hand, start at toes and compare each side - starting at groin feel down
- Ask the patient to close their eyes and use light touch to assess for any sensory deficit
Capillary Refill time
- Apply 5 seconds of pressure onto finger and release
- Should return in <2 seconds
- If >2 seconds suggests poor peripheral perfusion (hypovolaemia, congestive Heart Failure) and need to assess central cap refill
Gross motor
- Ask the patient to wiggle their toes
Gross sensation
- Ask the patient to wiggle their toes
Check oedema
- Is it pitting or firm
Palpate peripheral pulses
Start with radial and note rate and rhythm - establish what to palpate for in the legs
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Say you would start by palpating the femoral pulses and observe for radio-femoral delay - but not usually performed in OSCE.
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Popliteal arteries (popliteal fossa with flexed knee)
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Posterior tibial (behind medial malleolus)
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Dorsalis pedis (lateral to extensor hallucis longus tendon)
-
Aorta
Auscultation
- Listen for bruits over the aorta, renal arteries & femoral arteries.
Buerger’s test
- Ask the patient if they have any leg pain before
- With the patient reclined, hold the leg and slow raise it off the bed
- With arterial insufficient a point will be reached against gravity where the pressure cannot be maintained and the leg turns white
- In a normal patient the leg can be raised to 90 without compromise
- Then lower the pale limb back down over the edge of the bed
- Reactive hyperaemia occurs as the supply returns and characteristic pink-purple colouration of the skin
To Complete the Exam
- Explain to the patient that the examination is now finished.
- Thank the patient for their time.
- Dispose of PPE appropriately and wash your hands.
- Summarise your findings.
Further Assessments and Investigations
- Full Cardiovascular examination
- Lower limb neurological exam
- Upper limb vascular exam
- ABPI