Summary of Common Conditions Seen in OSCEs
| Condition | Symptoms | Signs |
| Intermittent claudication | Pain on exercise Relief on rest Location of pain dictates site of narrowing:
| ABPI = 0.8–0.06 (falsely high in diabetes mellitus due to calcified arteries) |
| Critical ischaemia | Intermittent claudication > rest pain > ulceration > gangrene Hangs leg out of bed while sleeping (which improves blood flow) – may sleep sitting up | The ‘6 Ps’ of an acutely ischaemic limb:
|
| Diabetic foot | Pain Skin changes Charcot joint: severe joint deformity due to lack of sensation and repetitive trauma | Loss of ankle jerk (autonomic neuropathy) Reduced vibration sense Ulcers |
| Amputation | Toes, lower leg or entire leg Social impact Buerger’s disease:
| Above knee Through knee Below knee |
Features of Arterial and Venous Lower Limb Disease
| Arterial | Venous |
| Shiny skin | Brown pigmented skin |
| Lateral malleolus | Medial malleolus |
| Deep ulcer | Shallow ulcer |
| Punched-out | Irregular sloping edge |
| Little exudate | Lots of exudate |
| Little/no swelling | Oedematous |
| Cold skin | Warm skin |
| No granulation tissue* | Granulation tissue* present |
| Pulses weak/absent | Pulses normal |
| Increased capillary refill time (>3 seconds) | Normal capillary refill |
*Granular dark red or pink tissue is seen in wound healing.
Important Investigations to Remember for This Station
- Bedside: ABPI, ulcer swab, ECG (arrhythmias and ischaemic heart disease), urine dipstick (glycosuria – diabetes mellitus screen)
- Blood: Full blood count, Us+Es, lipid profile, glucose
- Special tests: Colour duplex ultrasound, angiography
Basic Management of Peripheral Vascular Disease
- Conservative and medical:
- Exercise (there is evidence that this may have even better outcomes than surgery)
- Addressing risk factors (weight, smoking, blood pressure, cholesterol, glucose and aspirin).
- Other medications that may be used: cilostazol and naftidrofuryl
- Exercise (there is evidence that this may have even better outcomes than surgery)
- Surgical:
- Endovascular: percutaneous transluminal angioplasty
- Bypass
- Amputation
- Endovascular: percutaneous transluminal angioplasty
- Outcomes: approximately one-third improve, one-third stay the same, and one-third deteriorate.
Hints and Tips for the Exam
The arterial examination is an easy station and can allow you to demonstrate a number of clinical skills. Although you should undoubtedly look for and comment on features of acute conditions (such as acute limb ischaemia), seeing such a patient is almost impossible in the OSCE – if you do, it would be reasonable to stop your examination and get the patient admitted to the nearest surgical ward!
Adequate Exposure
When asking the patient to expose appropriately, ensure that you are clear and unambiguous. Ask them to remove their trousers, shoes and socks, leaving their underwear on. Some actors are told to keep their socks on unless specifically asked to remove them – forgetting this can lose you valuable seconds in the OSCE.
It is even more important to treat the patient in a dignified respectful manner, as many patients feel quite anxious when asked to expose their legs and abdomen.
Inspect Systemically
Inspection is fundamental in all of the vascular examination, and it is imperative that you are systematic – inspect either from the hips towards the feet or vice versa.
Ulcers
When examining for ulcers, make sure that you inspect all the pressure points and in between the toes (where an ulcer can easily be missed.) Lift each foot up to look at the heel, and use this opportunity to comment on the back of the leg as well. Arterial ulcers are classically ‘punched-out’.
When describing an ulcer comment on:
- Site
- Size
- Shape
- Edge
- Floor
- Exudate
- Surrounding skin
Palpating peripheral pulses
When palpating the pulses, it is easiest to start at the femoral arteries. If these pulses cannot be felt, the problem is above this level and the pulses below are unlikely to be felt. Never say that you can feel a pulse when you cannot! Simply add that you would like to have a Doppler scan at the end of the examination to assess the pulses you could not palpate.
The popliteal pulse is best felt with the patient’s legs slightly bent and relaxed. Grasp the calf with both hands. Place your thumbs on the tibial tuberosity and use your fingers to feel behind the knee in the popliteal fossa. The popliteal pulses can be difficult to feel so do not waste much time attempting this.
To save time, palpate both pairs of femoral and the foot pulses simultaneously. The abdominal aorta should be felt in the midline above the umbilicus (it bifurcates at L4 – below the umbilicus).
Don’t forget to check the capillary refill time as this is also a good indicator of perfusion – up to 2 seconds is normal, whereas more than 3 seconds shows that the limb is poorly perfused.
Buerger’s Test
This has traditionally been one of the most feared parts of the vascular examination – the following bullet point plan should make it easier for you:
- Ask the patient about pain in the hips, and ask whether you can lift their legs up.
- Lift both legs and note the angle at which the sole of the foot goes white.
- Note the angle made between the leg and the bed – this is Buerger’s angle (<20 degrees signifies severe ischaemia; normal is >90 degrees).
- Ask the patient to sit up from this position with their legs over the side of the bed:
- Comment on any change in colour of the legs: bluish (deoxygenated blood) and then red (reactive hyperaemia) if present.
As the station is quite straightforward, it can be incorporated with measuring an ABPI or be followed by questions on management of the common conditions. Knowing the arterial tree of the lower limb can assist you in your examination and impress the examiner when you finally present your findings (Figure 14.1).
Figure 14.1 Diagram of the arterial tree of the lower limb
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