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The cardiac assessment was concluded by assessing the lower limbs for pulses and oedema. The skin was of equal temperature bilaterally and had a capillary refill less than 2 seconds. Normal bilateral pulses were detected and the oedema noted to be pitting in nature, present in both legs and travel to mid-calf height. Several grading systems measure depth of indentation however O’Sullivan and Schmidt (2007) recommend a 1-4 scale that looks at depth of impression as well as the time to rebound. This represents a significant improvement on the scale developed by Brunner (1982) where oedema was graded only on how high up the limb it travelled. The relevance of distinguishing the presence of pitting oedema should not be overlooked (Whiting and McCready, 2016). Ely et al (2006) identified that the presence of pitting oedema is suggestive of DVT, venous insufficiency or lymphoedema.
A competent physical assessment of the abdomen is necessary to exclude serious pathology while helping to limit the exposure to unnecessary imaging (Moll van Charante and de Jongh, 2011). Due to the environment and patient’s mobility the examination would be severely compromised and as such offered limited value. Inspection revealed prominent bony structures with no evidence of caput medusae, a cardinal feature of portal hypertension (Raina and Sharma, 2015). Generalised palpation failed to elicit a pain response or identify any irregularities. It was not possible to perform percussion, a significant disappointment given ascites and peripheral oedema are common symptoms of heart failure, pericarditis and restrictive cardiomyopathy