– 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?
- Chronic ds (HTN, DM, DLP)
- MI, stroke, cardiac, vascular ds
- PE, DVT
- Medications: aspirin, anticoagulants, OCP
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- 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
- 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;
- Surrounding skin
2. Palpation: (ask pt if they have any pain?)
- Pitting edema
- Capillary refill
- Abdominal aorta “pulsatile, not expansile”
- Femoral (+ radio-femoral delay)
- Post tibial
- Dorsalis pedis
- Buerger’s test
- Bruits: carotid, abdominal aorta, femoral, popliteal
4. Movement: ask pt to wiggle their toes
5. Sensation + vibration + proprioception
– Investigations –
- 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)
- Duplex US
- 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
- 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)
|Distal (web space, dorsum of the foot)||Medial malleolus (+lipodermatosclerosis)||Planter|
|No pulses||Intact pulses||Intact pulses|
|Sharp||Irregular\sloping edge||Punched out|