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

 


– 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

 


– 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

PVD 1

 


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