Peripheral Vascular Disease Approach

– History –

• CC: most likely will present as claudication:
  • Site: where? Uni\bi-lateral? Does it radiate anywhere else (thighs, buttocks)?
  • Onset: first time? When\duration? Sudden\gradual? Continues\intermittent? Getting worse?
  • Timing and frequency: specific time of the day\night? How frequent?
  • Character: aching, cramping?
  • Aggravating\relieving factors: at rest? Exercise? Leg elevation? Dangling your feet?
  • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL? How many meters can you walk before experiencing pain? Reappears walking the same distance?

• Associated sx:
  • Constitutional: fever, chills, wt loss, loss of appetite?
  • Lower limbs: swelling, cold legs, numbness, weakness?
  • Skin changes: pallor, ulcers, dry skin, discoloration?
  • Other: chest pain, SOB, erectile dysfunction?

• PMHx:
  • Diseases:
    • Chronic ds (HTN, DM, DLP)
    • MI, stroke, cardiac, vascular ds
    • PE, DVT
    • Malignancy
  • Medications: aspirin, anticoagulants, OCP
  • Surgery, hospitalization, trauma
  • Blood transfusions, IV drug use, tattoos
  • Allergies

• FMHx:
  • Similar complaint?
  • Same diseases as in PMHx?

• Social Hx:
  • Occupation, marital status, children?
  • Smoking, alcohol, recreational drugs?
  • Travel Hx
  • Diet, exercise

 

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– Peripheral Vascular Physical Exam –

• WIPE, blah blah 🙂
• “Take vital signs”
• Position: lying flat
• Proper exposure: of both lower limbs
• Tell the pt it will be uncomfortable but not painful, and ask them to relax and take a deep breath

1. Inspection: (stand at the end of the bed)

• Deformities + muscle wasting
• Gangrene, missing toes, amputation
• Swelling
• Color: pallor, bluish, redness
• Skin changes: dry, shiny, hair loss, scars
• Ulcers + infections (between toes)
• Callus (bottom of foot)
• Describe the ulcer at the end, if there’s one;
  • Number
  • Site
  • Size
  • Shape
  • Margin
  • Floor
  • Edge
  • Discharge
  • Surrounding skin

 2. Palpation: (ask pt if they have any pain?)

• Temperature
• Pitting edema
• Capillary refill
• Pulses:
  • Abdominal aorta “pulsatile, not expansile”
  • Femoral (+ radio-femoral delay)
  • Popliteal
  • Post tibial
  • Dorsalis pedis
• Buerger’s test

3. Auscultation:

• Bruits: carotid, abdominal aorta, femoral, popliteal

4. Movement: ask pt to wiggle their toes

5. Sensation + vibration + proprioception

6. Reflexes

 

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– Investigations –

1. ABI:
   • Normal: 1 – 1.3
   • Claudication: 0.8 – 0.5
   • Rest pain: 0.5 – 0.3
   • Tissue loss: < 0.3
     • If abnormally high ABI (e.g. 1.8) w\ no palpable pulses, what does it mean? Calcification (b\c of DM)
2. Duplex US
3. Angio: CT, MRI, contrast angio

 

– Management –

• Risk factor modification (smoking cessation, control glucose, BP, hyperlipidemia)
• Antiplatelet therapy
• Exercise rehabilitation
• Foot care
• Medical Tx: Cilostazol, Pentoxifylline
• Revascularization:
• Endovascular therapy: angioplasty + balloon dilation, stents, endartectomy, thrombolysis
• Surgical bypass: for disabling claudication, critical limb ischemia

 

– Extra Info –

Parts of an ulcer:

• Margin: line of demarcation between normal and abnormal
• Floor: the exposed part of an ulcer (Inspection)
• Edge: the part between the margin and the floor of an ulcer
• Base: the structure on which the ulcer rests (Palpation)

ARTERIAL	VENOUS	NEUROPATHIC
Distal (web space, dorsum of the foot)	Medial malleolus (+lipodermatosclerosis)	Planter
Painful	+\- pain	Painless
No pulses	Intact pulses	Intact pulses
Sharp	Irregular\sloping edge	Punched out

 

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