Peripheral Vascular Disease Approach – Nada's Notes & Summaries

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– 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
• Skinchanges: 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:
2. Normal: 1 – 1.3
3. Claudication: 0.8 – 0.5
4. Rest pain: 0.5 – 0.3
5. 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)
6. Duplex US
7. 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)

ARTERIALVENOUSNEUROPATHIC

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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