Easy OSCE

Hamza Akram – Medicine 119

Vascular Exam & Approach

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 { SOURCES }
DR.RAJAB EID SUMMARY
GEEKY
ESSENTIAL OSCE
DR.MOHAMMAD AL-HEEH SLIDES
DR.ASEM SUMMARY

Preparation Before u start (WIIPPPE)

o Wash your hands
o Introduce yourself (name and position)
o Identity of patient (confirm name and date of birth)
o Light , temp , privacy
o Permission
o Pain?
o Position
✓ lying flat
✓ In venous start with standing
o Expose

✓ Lower limp —> from the umbilicus and below

✓ Upper limp

General appearance (end of bed)

o Well or ill
o Conscious unconscious
o Confused or not
o In respiratory destress or not , use accessory muscles or not
o Orientation to 3 (place , person , time )
o Position (lying in/comforetable on bed/simesetting position .
o Body weight : ——- BMI
o Color : He is jaundiced, cyanosed, pale.
o Objects & equipment

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 Don’t forget these concealed site
1- tip of toes. 5- between toes
2- lateral edge of foot 6- lateral malleoli
3- heels. 7- ischial tuberosity
4- scarum

Inspection
I. From end of bed (compare both limp) —>looking at Symmetry by:
1. Size[Edema].◻.
2. Shape —> Normal/edema/atrophy ◻.
3. Color (but do not consider it asymmetric if involve only small area)
o Pallor [PAD]
o Dusky Red [depending pool in PAD]
o Blue [PAD]
o Mottled discolouration [ALI]
o Blue-Black [Gangrene]
o Brownish [CVI]
4. If you see ulcer , Forign body ◻ ( dressing,……)
5. Amputation ◻ , Deformity ◻

II. From right side

➢ Atrophic changes:[PAD].
1. Shiny skin◻.
2. Pigmentation◻.
3. Hair loss◻.
4. Nail thick ◻
5. Muscle atrophy◻. (In upper limp thiner &hypothiner , in lower limp calf)
o Others —> Guttering Vein ◻. Ulcers ◻. Gangrene◻
➢ Venous Changes [CVI ] [look with pt stand first] —> mostly in Gaiter area
o Dilated Vein. Venous star ◻(<1 mm dilated vein)
Reticular Vein ◻ (1-3 mm vein).
Varicose Vein ◻ (>3mm vein)
o Lipodermatosclerosis ◻(due to stasis of WBC , May cause ‘inverted champagne bottle’ legs)
o Brownish pigmentation ◻(due to hemosidrin from RBC)
o Atrophy Blanche (white areas of skin where underlying veins)
o Eczema ◻
o Erythema ◻(in veins course)
o Blow out sign ◻
➢ Ulcer. [to describe ulcer look for Ulcer file]
o Arterial Ulcer◻
o venous Ulcer ◻
o pressure Ulcer◻
➢ Scars ◻

Hemosidrin Eczema
osis

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 Palpation
I. Temperature (both limp /distal to proximal/ By your dorsum)
o Normal (symmetrically warm)
o Cold◻[PAD , ALI]
o Warm ◻[thrombophlebitis , CVI]
II. Tenderness ◻ (eye contact/ ask for pain, thrombophepitis)
III. Edema (press against bone) Pitting/non pitting◻. Symmetric /asymmetric◻
IV. Capillary refill ◻ (NR=2-3 sec , apply pressure to 5 sec
V. Peripheral pulses (from distal to proximal, Both limp)

VI. Others in venues problem suspicion

➢ Palpate Saphenofemoral incompetence
➢ SFJ —> ~2cm inferior & lateral to pubic tubercle —> saphena varix (dilated SFJ)
➢ Cough impulse with palpate SFJ —> for competence of SFJ valve
➢ Palpate Vein Course. —> for lipodermatosclerosis & tenderness
1. GSV —> from medial feet , anterior to Medial malleolus , along medial aspect of calf &
thigh , then join with femoral vein to form SFJ
2. SSV —> lateral feet , posterior to lateral malleolus , along lateral aspect of calf , join
with popliteal vein to form SPJ

Peripheral Pulses
Dorsalis pedis ◻ 1. Lateral to extensor hallucis longus lig.
2. B/W 1st & 2nd metatarsals
3. Against navicular bone
❖ Continuation of anterior tibial artery
Posterior tibial ◻ 1. Behind and inferior medial malleolus by 1 finger(~2 cm)
2. Half way between medial malleolus and Achilles tendon
3. distance from medial malleolus to heel ( BW proximal & middle 1/3)

Peroneal artery ◻ cannot palbaple

Popliteal artery ◻ 1. Flex knee 135 degree +put your 4 fingers in popliteal fossa+your thumbs on tibial
tuberosity
2. Patient in supine position, knee straight, put your 4 fingers in popliteal fossa and your
thumbs parallel to them on thigh of shin bone
3. Patient in prone position
✓ Not easily palpated (if easy palpated may popliteal aneurism)
Femoral artery ◻ in mid-inguinal point (halfway B/W ASIS and pubic symphysis)
o Femoral Pulse
o Radio-Femoral delay
Radial Artery◻ at radial side of wrist , lateral to flexor carpi radialis
o Radial Pulse
o Radio-Radial delay
Brachial Artery◻ in antecubital fossa , medial to Biceps tendon , against medial epicondyle
Carotid Artery◻ between the larynx and the anterior border of the SCM muscle
o Auscultate firstly
o Then palpate pulse
Superfecial temporal ◻
Abdominal aorta◻ Above umbilicus about 2 cm
o Inspect (visible pulsation)
o Auscultation (bruet)
o Palpation ( pulse)
Renal artery ◻ Above & lateral to umbilicus about 3 cm

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 Percussion
➢ Schwartz test (video)—>in V.V
✓ Procedure
1. Put your hand in vein
2. Tap with other hand on vein
✓ Result
o If impulse felt —> +ve — incompetence of valves in superficial venous system.

Auscultation
I. Femoral bruit ◻(femoral or iliac stenosis)
II. Carotid bruit ◻(carotid stenosis)

Sensation
(Just from Geeky, doctors didn’t mention it , as nervous Exam in Internal medicine)

1. Ask the patient to close their eyes whilst you touch their sternum with a wisp of cotton wool to
provide an example of light touch sensation.
2. Ask the patient to say “yes” when they feel the sensation.
3. Using the wisp of cotton wool, begin to assess light touch sensation moving distal to proximal,
comparing each side as you go by asking the patient if it feels the same:
o If sensation is intact distally, no further assessment is required
o If there is a sensory deficit, continue proximally until the patient is able to feel the cotton
wool and note the level at which this occurs.

Remember that: Remember that:

✓ The midpoint of the inguinal ligament, halfway between ✓ Normally popliteal Pulse is difficult to feel
the anterior superior iliac spine and pubic tubercle, is the ✓ when a popliteal pulse is very easy to feel, the
landmark for the femoral nerve. artery may be aneurysmal;
✓ The mid-inguinal point, halfway between the anterior ✓ the popliteal pulse should be palpable if the
superior iliac spine and the pubic symphysis, is the foot pulses are easy to feel and there are no
landmark for the femoral artery. adductor canal or femoral artery bruits.

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 Special tests-Arterial
A. Bureger test +ve Test ◻[critical PAD]—> Leg reactive hyperaemia (deep red)
[video] -ve Test ◻[normal]—> leg return to normal

Buerger Angle Procedure

1. Pt lying flat
✓ the angle to which the leg has to be raised before it 2. Elevate leg at 45 degree for 2-3 min
becomes white.& Guttering of the veins 3. Leg look pallor
✓ Angle B/W sternum and heel 4. Quickly sit pt & hang his leg
✓ lower angel (<30) —> sever disease 5. Result

B. Allen test [video]

o Abnormal Test ◻—> hand still pale in radial artery after release pressure on ulnar (
poor collateral)
o Normal Test ◻—> all hand return to normal colour after release pressure (good
collateral)

Procedure
Allen Test 1. Patient supine position and hand elevated
➢ Done before ABG , Cardiac Cath , AV shunt , if we need radial for CABG 2. ask him to open and close hand for 15-30
➢ Used to assess radial & ulnar arteries & collateral between them seconds
➢ Complication —> infection , dissection , thrombosis 3. ask him to clench his fist
➢ If blood supply from one of arteries (Radial & Ulner) is cut off, the other 4. Pressure over ulnar and radial arteries —>to
artery can supply adequate blood to the hand due to presence of collateral occlude both of them.
branches between then in the hand. But some people lack collateral or may 5. hand then opened, It should appear
one of them narrowed blanched ( pale)
➢ Ulnar a. Is prominance in hand 6. Ulnar pressure is released while radial
pressure is maintained
Normal result 7. look for color
Abnormal result

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See this video —> click here

Special Test -Venous

I. Perths test —> if problem from deep vein or from superficial vein?
• Used for assessing the patency of the deep veins
• Procedure
o When pt supine —> Rise leg & milking vein
o Put tourniquet around the thigh
o Ask the patient to raise their heels off the ground ten times
• Result
o If superficial vein collapse —> deep veins normal —> so problem in superficial
veins
o If superficial vein remain dilated —> deep veins incompetence —> so problem
is deep veins
II. Brodie Trendelenburg test [Video] —> problem in SFJ or in perforator?
• This is to assess the competence of the SFJ
• Procedure
o patient should lie on a bed
o limb elevated to 45 degree
o then empties veins by milking it toward the heart.
o Use our hand to occlude SFJ (also u can use Tourniquet and them called
Tourniquet test)
o The patient is then asked to stand up and legs are observed for 30–60 seconds
• Result
Result During oclude SFJ After release Hand from SFJ
pure SFJ incompetent -ve (vein not dilated) +ve (veins become dilated)
pure perforators +ve (veins become dilated) -ve (vein not dilated)
incompetent
mixed SFJ and perforators +ve (veins become dilated) +ve (veins become more dilated)
incompetent

III. Multble Tourniquet Test [Video] —> in any site perforator is incompetance ?
• Used to locate the site of incompetent perforator
• Procedure
o The patient should lie on a bed,
o the limb is elevated to 45 degree
o thin empties the veins by milking it toward the heart.
o placing tourniquets in upper thigh, mid-thigh, below knee
o The patient is then asked to stand up and the legs are observed for 30–60 seconds
• Result
o If VV’s appear between tourniquets: this means that perforators are incompetent
o If no VV’s appeared: this means the saphenous vein valve is incompetent ( as
tourniquets now act as valves that prevent back flow, but we remove tourniquets,
VV’s will appear again)

To complete Exam
✓ Examine upper limp Pulses
✓ Examine Carotid Artery [auscultation+
palpation]
✓ BP measurement
✓ ABI Page 7 of 17
✓ Dopplex U.S
Arterial & Venous Anatomy

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Vascular Ulcers

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 ABI

Fontaine classification

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 Arterial Disease Approach

Acute Limp Ischemia (ALI) Chronic limp ischemia

Definition Sudden decrease in perfusion to a limb Inadequate arterial supply to meet cellular
that endangers its viability metabolic demands during walking (claudication) or
at rest (critical limb ischemia) and occurs due to
atherosclerosis
Hx 1. Ask about Pain : 1. Ask about pain (claudication)
o Site o Site (mostly in calf)
o Onset (suden) o Onset (gradual )
o Character o Character (cramping , aching)
o Radiation o Radiation
o Association (6P) o Association ( ischemic signs)
▪ Paresthesia (1st) ▪ Hairless
▪ Pain (most pt presentation) ▪ Muscle atrophy (inverted champagne bottle)
▪ Pallor ▪ Shiny dry cold skin
▪ Pokilothermia ▪ Pigmentation
▪ Thick nails
▪ Pulselessness
o Time (Intermittent)
▪ Paralysis( last , irreversible
o Exaceriprating & reliving factors
damage )
▪ Increase with walking & improve by rest —>
o Time (ideal 6-8 h)
claudication
o Exaceriprating & reliving factors ▪ Increase by with lying flat or in night &
o Severity Improve hanging leg—>rest pain
2. Ask about causes & R.F : o Severity
o Thrombosis—> DM , smoking , lipid, 2. Ask for walking distance & Claudication
obesity , old , ask for claudication distance.
o Embolus 3. Ask for rest pain (continuous , worse in night)
▪ Cardiac —> arrhythmias , A.Fib , 4. Ask about R.F of atheroscelorosis —> male ,
previous MI , valvular dz , DM, HTN , lipid , smoking , age , obesity
▪ arterial aneurysms 5. Look or Ask for ulcer , gangrene , necrosis
▪ atheroembolism 6. Ask about other claudication causes :
o Iatrogenic or direct Trauma ▪ Neurogenic —>numbness, paresthesia,
o Vasospasm —> medication or coldness but without discolouration of his
Vasospastic disease limb
3. FH —> CAD , DM , HTN , athero. … ▪ orthopaedic —>patient has pain by the first
4. PMH —> CVD , DM , HTN , lipid , MI step
,aneurysm , HIT, hypercoagulopathy 7. FH —> CAD , DM , HTN , athero. …
5. PSH —> cardiac , vascular , cath , 8. PMH —> CVD , DM , HTN , lipid , MI ,aneurysm ,
6. Drug & allergy Hx HIT, hypercoagulopathy
7. Social Hx 9. PSH —> cardiac , vascular , cath ,
8. Systemic enquiry 10. Drug Hx & allergy —> BB can lead to claudication
11. Social Hx
12. Systemic enquiry

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 P.E • Vascular Exam •
Vascular Exam
• Cardio Exam •
To diff. From ALI —> palpation of pulse to
• Examine 6P contralateral limb (e.g dorsalis pedis) if weak or
absent so it is likely to be CLI but if present and
good it is likely to be ALI
Lab CBC , Lipid profile , ECG , CXR , glucose , HbA1c , lactate ,
Images 1. Dopplex US 1. ABI (if >1.3 can u make TBI)
2. CT angio o 0.9-1.3 normal
o To demonstrate site o >1.3 arterial calcification (DM)
o Clue for etiology o 0.7-0.8 —>mild
o Provide information about other o 0.5-0.6–> moderate
arteries o 0.3-0.4–> severe
o < 0.3—> Critical limb ischemia
2. Dopplex US
3. Angiography
4. CT angiogram
Management ➢ Immediate management According to Fontaine Classification
1. heparin with 1cc bolus (1st thing) ➢ Stage 1 & 2
2. Pain killer o conservative management
3. place leg in depednent position 1. Lifestyle modifications
4. IV-Fluid ▪ smoking cessation
Then surgical management ▪ Walking exercise program (only thing
I. Revascularisation can increase walking distance )
1) Fogarty catheter ▪ foot care (especially in DM):
▪ Motor & sensory preserved or 2. R.F modifications
senory loss + motor preserved ▪ DM control
▪ HTN control
▪ Lipid control
2) Open 3. Medications
▪ If motor loss & sensory ▪ ASA & Statin (lifelong)
loss ▪ Cilostazol
▪ Done by Embolectomy or ▪ Pentoxyphylline (increase RBC
Bypass deformability , lowers blood viscosity
and increase flow)
I. Amputation ➢ Stage 3 & 4 (may with 2b)
▪ If motor loss + sensory loss + o Surgery
tissues loss & damage 1. Open bypass
2. Endovascular ballooning +/-stent
3. Amputation ( if gangrene , ABI<0.3)
Notes ❖ M.C site of arterial occlusion by an ❖ M.C site of arterial occlusion from atherosclerosis is
embolus is common femoral artery superficial femoral artery (distal 1/3 of when enters
❖ Sensory & motor loss are prognostic Hunter canal)
❖ Patient with paralysis as a late sign of ALI ❖ Anemia , BB drug —> can cause claudication
will not have pain or sensation ❖ 65% of athero. Occur below inguinal lig
❖ Complication of revasculrization of ALI —> ❖ Patient with CLI will never have paralysis.
ischemic reperfusion syndrome —>free ❖ Patient has dossalis pedis pulse but no femoral pulse
radicals : —> if collateral presence , to be sure ask pt to walk
• High K , high Lactate released to blood

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 • Rhabdomyolysis until feel pain then palpate dorsalis pulse it will be
• AKI decreases
• Compartment Syndrome ❖ Critical limb ischemia:
❖ Rest pain
❖ ABI <0.3 (ankle systolic pressure > 50 mmHg or Toe
pressure >30 mmHg)
3. ulcer or gangrene
➢ Intermittent claudication: cramping muscle pain, mostly in the calf, brought on by walking many steps but
not the first step, relieved by standing and stop walking without change in position (most common in calf)
➢ Walking distance: the distance in meter the patient can walk before he stop for relieving the pain ( it may
differ from day to day depending on patient status, mood, activity”
➢ claudication distance: distance covered by the time walking has to stop
➢ Rest pain: pain that occurs at rest, mostly in the foot, for more than 2 week, with regular use of analgesia,
and it get worse at night “ as patient lying flat and elevate his leg” and relived by hanging leg out of bed

DDx of leg Pain Subclavian steal syndrome

➢ retrograde blood flow in the vertebral artery due to a
proximal stenosis and/or occlusion of the subclavian
artery
➢ Clinical Features
1. Stenosis in subclavian artery proximal to the
origin of vertebral artery
2. Patent vertebral artery
3. Exercise in upper limb
4. syncopal attacks, vertigo, confusion, dysarthria,
blindness, ataxia
5. vertebra-basilar insufficiency
6. Upper extremity claudication ( theoretically,
patient who experience cerebral hypoperfusion
symptoms will stop exercise before claudication
occur)

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 Approach to venous

Varicose vein
Hx & P.E 1. Ask about varicose vein or swelling
• Onset & duration
• Unilateral or Bilateral
• Other features ( other pt presentation )
✓ Cosmetic
✓ Hotness (due to venous stasis )
✓ Heaviness
✓ Itching (due to histamine extravasation )
✓ Night cramping
✓ Bleeding from leg (severe bleed)
✓ Ulcer (look for Ulcer file) —> due to extravasation of proteolytic enzymes
✓ Lipodermatosclerosis (proteolytic enzymes & hemosiderin accumulation in skin)
✓ Superficial thrombophlebitis (stasis of blood & WBC accumulation )
▪ hotness, redness, tenderness, cord-like structure
▪ Fever , discharge (if infected) —> give Antibiotic
2. Ask for R.F
• Old Age
• Gender —> equal male & female !!
• Pregnancy:
o Due to increased blood volume
o Hormonal effect that cause weakness in vessel wall
o Enlarging uterus increase intra-abdominal pressure
• Causes of increase intra-abdominal pressure —> chronic cough, chronic constipation
• Occupation:
▪ Heat: as who work in ovens as heat cause vasodilation
▪ Prolonged standing , prolonged sitting
• Diet —> hormonal food
• Tight cloths: especially in the thigh region which will cause stasis of blood on lower veins
• Family history
• Tall person
• Obesity (due to increase hormone , sedentary life style)
3. PMH & other Hx parts
P.E • Vascular Exam
• Harvey sign (delayed venues refill )—> put 2 index fingers side byside on vein then release
distal finger & look for refilling
Lab
Images ✓ Dopplex U.S (dopplex = image + sound) (doppler = just sound )
✓ Others —> Varicography , Venography
Management • Compressor socket
➢ Superficial thrombophlebitis
o Tx —> anti-inflammatory
o Give A.B only if infected —> fever , discharge
o Give anticoagulation only if —> Involved SFJ , Involve > 5 cm
➢ Spider VV’s —> sclerotherapy or laser (may cause thrombosis in vein)
➢ Reticular: Sclerotherapy only
➢ Saphina varix —> high saphenous ligation

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 ➢ Varicose vein
• If small: sclerotherapy
• If large: there are 3 options Indication for VV surgery
1. Surgery (ligation & stripping of vein) 1. Ulcer
2. Laser 2. Symptomatic
3. Radiofrequency 3. Recurrent
▪ Both has higher recurrence rate than surgery 4. Thrombosis
▪ Expensive 5. Skin changes
▪ done if above knee
▪ But they have less pain and ecchymosis
Notes ❖ Left side > right side —> right common iliac artery compress left common iliac vein
❖ In deep vein —> CVI , no V.V
❖ In superficial vein —> V.V
❖ No V.V in upper limp , just may normal dilated vein
❖ Why gaiter area is m.c of venous ulcer ?
1. high pressure in that area in GSV
2. Cockett's perforators which become incompetent after prolonged period of increased
deep vein pressure
❖ VV’s occur only in the superficial veins (deep veins are supported by muscle)
❖ Complication of VV Sx —> thrombophlebitis , bleeding , DVT , nerve injury [suphenous
nerve with GSV , sural nerve with SSV)
Classifications of VV’s
➢ According to diameter:
1. < 1mm : spider VV’s (usually pink)
2. 1-3 mm: reticular VV’s (usually purple)
3. 3-15 mm: varicose veins

➢ According to involved vein

1. Typical: one of 3 main vein involved. ( GSV, SSV, GV)
2. Atypical: other veins involved as in other veins in leg, scrotum , vagina, pelvis ( pelvis
congestion syndrome)

➢ According to cause
1. Primary: most VV’s are primary
2. Secondary:
▪ post-phlebitic syndrome
▪ post-thrombotic syndrome
▪ congenital syndromes
✓ klippel Trenaunay syndrome (VVs + vascular malformtion + unilateral soft & skeletal
hypertrophy )
✓ Parkes Weber syndrome ( as klipper + AV malformation )

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 3 types of vein in lower limb
❖ Separated by fascia , connected by perforators
1. Deep veins ( which are usually accompanied by nerve and artery & within muscles —> VV don’t
occur in deep veins
2. Superficial veins: most important veins are:
✓ Great saphenous vein ”GSV”: arise from medial aspect of dorsal foot, then pass anterior to
medial malleolus, then ascend along medial side of the leg and thigh and empty in sapheno-
femoral junction
✓ Small saphenous vein ”SSV”: arise from lateral aspect of dorsal foot, then pass posterior to
lateral malleolus, , then ascend along lateral side of the calf, then go to the posterior aspect
of upper calf then enter the fascia and join popliteal vein in sapheno-popliteal junction
✓ Giacomini vein: courses the posterior thigh and is a communicant vein between the GSV and
SSV
3. Perforator veins: there are many, they connects between Superficial and Deep venous system,
examples:
✓ Dodd's perforator
✓ Boyd's perforator
✓ Cockett's perforators at the inferior 2/3 of the leg ( the connected to posterior crural arch of
GSV)
- At the junction SFJ and SPJ there also a valve to prevent back flow from deep to superficial system
- Perforators have valves to prevent flow of blood from deep to superficial ( as deep vein has higher pressure)
- saphenous nerve is a branch of the femoral nerve that runs with the great saphenous vein
- sural nerve runs with the small saphenous vein (most nerve to be biopsied in general)
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