Aortic stenosis Hands The hands can provide lots of clinica | Go Away...
Aortic stenosis
Hands
The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.
Inspection
General observations
Inspect the hands and note your findings:
Colour: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. aortic stenosis, coronary artery disease, hypertension).
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. aortic stenosis, coronary artery disease, hypertension).
Palpation
Temperature
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
Capillary refill time (CRT)
Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:
Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.
Pulses and blood pressure
Radial pulse
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Brachial pulse
Palpate the brachial pulse
Palpate the brachial pulse in their right arm, assessing volume and character:
1. Support the patient’s right forearm with your left hand.
2. Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated.
3. With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus. Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.
Types of pulse character
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation and also CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
Blood pressure
Measure the blood pressure
Measure the patient’s blood pressure in both arms (see our blood pressure guide for more details).
Blood pressure abnormalities
Blood pressure abnormalities may include:
Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old).
Hypotension: blood pressure of less than 90/60 mmHg.
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.
