EXAMINATION OF AXILLARY VEIN THROMBOSIS INSTRUCTION: EXAMINE RIGHT ARM OF THIS GENTLEMAN. TO PATIENT: HELLO MR. ANTHONY.

MY NAME IS DR. NAZISH GHAZANFAR. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY. MAY I PLEASE EXAMINE YOU? THANK YOU. LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS. COULD YOU PLEASE TAKE OFF YOUR SHIRT SO THAT I CAN LOOK AT BOTH YOUR ARMS AND SHOULDERS? PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL. ARE YOU CONFORTABLE SIR?. DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG? I AM JUST GOING TO HAVE A LOOK FIRST OF ALL. TO EXAMINER: THERE IS ON INSPECTON IN THIS GENTLEMAN NO SIGN OF HORNERS SYNDROME. FULLNESS AT THE ROOT OF THE NECK IS NOT PRESENT. THE ARM, FOREARM, HAND AND FINGERS OF RIGHT SIDE ARE MARKEDLY SWOLLEN, CONGESTED AND BLUE.THE SURFACE VEINS ARE DISTENDED WITH ENLARGED COLLATERAL VEINS OVER THE SHOULDER AND ANTERIOR CHEST WALL. TO PATIENT: SIR, CAN YOU PLEASE RAISE YOUR ARMS ABOVE YOUR HEART LEVEL? TO EXAMINER: WHEN THE HAND IS RAISED ABOVE THE LEVEL OF THE HEART , VEINS AT THE BACK OF THE HAND OR ARM DO NOT COLLAPSE. TO PATIENT: PLEASE PLACE YOUR HANDS ON THIS PILLOW PALMS UPWARDS. TO EXAMINER: THE HAND AND FINGERS OF RIGHT SIDE IS MARKEDLY SWOLLEN, CONGESTED AND BLUE. THERE IS NO EVIDENCE OF ULCERATION OR GANGRENE ON FINGER TIPS. FINGER PULP ATROPHY AND WASTING OF SMALL MUSCLES OF HAND IS NOT EVIDENT. TO PATIENT: I AM NOW GOING TO FEEL YOUR ARMS. ARE THEY TENDER AT ALL? I WILL BE VERY GENTLE. TO EXAMINER: THE RIGHT ARM IS WARMER THAN THE LEFT. IT IS TENDER. TO PATIENT: I AM JUST GOING TO PRESS ON YOUR HAND FOR FEW SECONDS. TO EXAMINER: PITTING EDEMA IS PRESENT ON DORSUM OF RIGHT HAND. I CAN FEEL A TENDER CORD ALONG THE COURSE OF AXILLARY VEIN (WHICH IS THE CONTINUATION OF BASILIC VEIN ON THE MEDIAL SIDE. IT LIES MEDIAL TO AXILLARY ARTERY AND ENDS AT OUTER BORDER OF FIRST RIB TO BECOME SUBCLAVIAN VEIN.) TO PATIENT: I AM NOW GOING TO TEST FOR CAPILLARY REFILL. AND NOW THE OTHER SIDE. TO EXAMINER: CAPILLARY REFILL IS NORMAL. TO PATIENT: I AM NOW GOING TO FEEL THE RADIAL PULSE. TO EXAMINER: THE RADIAL PUSE IS 70 BEATS PER MINUTE AND IS REGULAR. IT IS NOT COLLAPSING AND THERE IS NO RADIORADIAL DELAY. TO PATIENT: I AM NOW GOING TO PULL ON YOUR ARM DOWNWARDS AND FEEL RADIAL PULSE AGAIN. AND NOW THE OTHER SIDE.

TO EXAMINER: THE RADIAL PULSE IS PRESENT AND UNDIMINISHED. NOTE: FOR ALLENS TEST AND FOR OTHER PULSES CHECK MY NOTE ON EXAMINATION OF RAYNAUDS DISEASE. IT IS EXPLAINED IN DETAIL THERE. TO PATIENT: I WILL NOW PERFORM ALLENS TEST. CAN YOU MAKE A FIST? AND NOW OPEN YOUR PALM. THANK YOU. TO EXAMINER: THE RAIDAL ARTERY LOOKS PATENT. TO PATIENT: CAN WE DO THAT AGAIN? PLEASE MAKE A FIST. NOW OPEN YOUR PALM. THANK YOU. TO EXAMINER: THE ULNAR ARTERY LOOKS PATENT. TO PATIENT: I AM NOW GOING TO CHECK OTHER PULSES IN THE ARM AND NECK. TO EXAMINER: THE UPPER LIMB PULSES ARE NORMAL AND UNDIMINISHED. TO PATIENT: I AM NOW GOING TO FEEL IN THE SUPRACLAVICULAR FOSSA FOR CERVICAL RIB AND LYMPHADENOPATHY. IS IT TENDER HERE AT ALL? TO EXAMINER: THERE IS NO PALPABLE CERVICAL RIB OR CERVICAL LYMPHADENOPATHY. TO PATIENT: I AM NOW GOING TO LISTEN FOR A BRUIT IN SUBCLAVIAN ARTERY. TO EXAMINER: THERE IS NO BRUIT OVER SUBCLAVIAN ARTERY. TO PATIENT: I AM NOW GOING TO TEST FOR SENSATION IN UPPER LIMB. CAN YOU FEEL ME TOUCH YOU HERE? DOES IT FEEL THE SAME AS ON THE OTHER SIDE? TO EXAMINER: SENSATION IS INTACT. TO PATIENT: SIR, CAN YOU MOVE YOUR FINGERS, HAND, FOREARM AND ARM WITHOUT ANY PAIN? TO EXAMINER: FINGER MOVEMENTS ARE DIMINISHED AND THE MOVEMENT OF THE REST OF THE ARM IS LIMITED ONLY BY PAIN AND SWELLING. TO PATIENT: THANK YOU SIR. YOU MAY WEAR YOUR SHIRT NOW. TO EXAMINER: TE DIAGNOSIS IS AXILLARY VEIN THROMBOSIS. TO COMPLETE MY EXAMINATION I WOULD LIKE TO TAKE BLOOD PRESSURE IN BOTH ARMS, PERFORM A CARDIOVASCUAR AND NEUROLOGICAL EXAMINATION OF UPPER LIMB. I WOULD LIKE TO WASH MY HANDS.