WEEK 15: Peripheral vascular system – History
PAD
1. Acute: Sudden onset of severe pain in a pale, cold, pulseless limb which also starts to feel numb and tingly.
6Ps(soft signs: pulselessness, pallor, perishingly cold; hard signs indicate a threatened limb: parasthesia; paralysis;
pain on squeezing muscle) => loss of motor and/or sensory loss most indicative of severe nerve ischaemia; limb will
become irreversibly damaged unless circulation restored within a few hrs; muscle tenderness indicates impending
muscle infarction;
On Examination:

Skin will appear blue/marble white, progressing to dark purple (and not blanching) and gangrene (black)
Causes: embolic(usually cardiac in origin eg AF); thrombotic; compartment syndrome(increased pressure in a fascial
compartment often following trauma which compromises perfusion)
2. Chronic:
1.
Intermittent claudication
2.
Rest pain
3.
Pain all the time
4.
Pain relief when legs lower than heart (eg hanging it out of bed when sleeping)
On Examination: ischaemic changes present

Cold/numb sensation of extremities

Smooth, shiny, dry skin with no hair on legs

Thickened/brittle toenails (trophic changes)

Pale/blue foot

Pallor when extremity raised

Delayed capillary filling

Diminished/absent pedal pulses

Small, circular, painful ulcers over bony prominences

Atherosclerosis is main cause (hence RF=age, males, smoking, DM, hyperlipidaemia, hypertension)

+ve Buerger’s test; ankle BP <50mmHg
Peripheral venous disease – chronic venous insufficiency(CVI), varicose veins due to CVI; DVTs
1. Varicose veins – in greater saphenous and small saphenous veins
Result from incompetent valves that allow veins to become engorged with blood(backflow through veins)
Familial tendency, age, females, obesity, posture/increased pressure(worse when person erect – link to occupation)
Pregnancy, constipation, pelvic tumour reduce venous return by increasing abdo pressure
On Examination:
 Normal pulses
 Brown patches of discolouration on lower legs
 Oedema/swelling
 Irregularly shaped, painless ulcers on ankles – may lead to varicose eczema(stasis dermatitis)
 Cyanosis and pain at rest
 Pain relief when legs elevated – assists venous return
 No intermittent claudication
 Normal nails
 Lipodermatsclerosis (skin hardness from subcut fibrosis caused by chronic inflammation and fat necrosis) =
inverse champagne bottle appearance
2. DVT:
 Unilateral swelling distal to the site
 Unilateral tenderness
 Unilateral leg pain
 Warmth
 Discolouration
 Homan sign in 10% pts – discomfort in calf during gentle, forced dorsiflexion of foot
 RF – female, the pill, bed rest, obesity, long haul flights, fractures of lower extremity
Other Presenting Complaints
Pain on exertion or at rest
Skin Changes
Rationale
Pain area = problem from 1 level proximally (eg. Pain in thigh=problem with
common femoral/iliac a; pain in calf=problem in superficial femoral a)
Cold hands and or feet
Loss of/ reduced sensation/function
Profound ischaemia(embolism) – no chance for collateral circulation to
develop; thrombosis is more gradual
Swollen ankles, palpitations, SOB
HPC: SOCRACTES
Past Medical history
Any similar problems in the past?
Any admissions to hospital?
Any recent illnesses?
Any chronic conditions?
No.of pregnancies?
AF
JADE, TAB, MARCH, thyroid
Drug History
Allergy; drug dose/compliance
Analgesia
Anti-coagulant therapy
Statins
Anti-hypertensives
Peripheral vasodilators
GTN spray
HRT
Insulin
Contraceptive pill; pregnancy
Thyroxin (T3)
Social History
Smoking (pack years)
Alcohol
Occupation
Exercise
Diet
Immobility
Overseas / long distance travel
Family History
PVD
Parents alive?
Other
Rationale
Hip fracture – immobility leading to stasis
May send emboli off
Rationale
DO NOT GIVE WARFARIN TO PVD PT WHO HAS HAD A STROKE
If pt has AF; but this increases risk of PE
Hypercoaguable blood
Hypercoaguable blood so increased risk of DVT
Rationale
Stasis of blood
Illness, surgery, varicose veins, immobility of old age
Stasis of blood
Rationale
DM, high cholesterol, hypertension, CVA, MI
Ask ‘Have your parents ever suffered a clot in the leg(DVT)/lung(PE)?
Inherited – protein C deficiency, protein S deficiency, Factor V Leiden mutation, anti-thrombin
III deficiency, etc; Connective tissue diseases – Marfan’s syndrome(AAA)
Increased blood viscosity: polycythaemia, myeloma, ? severe dehydration
Hypercoaguable blood: Acquired: ‘Systemic’ : collagen diseases, Antiphospholipid
syndrome, malignancy, nephrotic syndrome, tissue trauma (including surgery); ‘Local’ :
compression / injury to venous system e.g. tumour in the pelvis
Check ICE in pts with PVD as often presenting complaint
4 major ways in which PAD pts present:
A. Limb symptoms
Legs more commonly affected than arms due to more atherosclerosis and a less well developed arterial supply
Stage Presenting
Rationale
complaint
I
Asymptomatic ABPI <0.8 at rest; asymptomatic because pt is limited by other pathology or they choose not
to walk very far
Arterial claudication: Most common symptom of PAD; cramp-like pain felt in the legs due
II
Intermittent
claudication
to arterial insufficiency after a relatively constant distance and sooner if uphill; pain
(sensory loss
disappears after a few mins of rest+restarts again on exercise; typical felt in the calf due to
in foot –
femoropopliteal disease but may be felt in thigh/buttock if aorto-iliac disease. Claudication
‘walking on
distance = distance pt can walk before pain starts(often underestimated)
Sharp pain, acute onset, pale whole leg, then no pain – most probably due to thrombosis
pebbles’);
Neurogenic claudication: leg pain due to neurological and musculoskeletal disorders of
III
Night/rest pain
IV
Tissue loss
(ulcerartion/
gangrene)
lumbar spine
Venous claudication: leg pain due to venous outflow obstruction following extensive deep
vein thrombosis
Dull pain, chronic onset, local changes – most probably due to slow ischaemia (though DVT
can be quite quick!)
Pt goes to bed but is woken up 1-2hrs later with pain in their foot; due to the lost beneficial
effects of gravity on lower limb perfusion; sleep also reduced HR, BP and CO. Pt often gets
relief by hanging leg out of bed, or sleep in a chair. Ass symptoms: SOB(OE), erectile
dysfunction
Trivial injuries do not heal allowing bacteria to enter leading to ulcers/gangrene; may lead to
amputation/death
Chronic or acute arterial changes
B. Neurological symptoms
Presenting Complaint
Carotid artery territory
Vertebrobasilar artery territory
C. Andominal symptoms
Presenting Complaint
Visceral ischaemia
Abdominal aortic aneurysm(AAA)
Rationale
Half of TIAs+strokes are due to an embolism from an athermatous plaque at the
common carotid bifurcation.
Site somatic, speech, visual, Onset sudden, Duration <24hrs, crescendo?
Character “like a shutter coming down” blackness, tunnel vision Association +
tingling, speech disturbance, facial/limb weakness.
See CNS exam and lecture notes for more info.
Giddiness; collapse; transient occipital blindness. Subclavian artery
stenosis/occlusion proximal to origin of vertebral artery may result in ‘subclavian
steal’ syndrome: during arm exercise, blood travels up the carotids, via the Circle
of Willis, down the vertebral artery, ‘stealing’ the blood from the posterior cerebral
territory, causing stroke-like symptoms. Signs=asymmetry in pulses+BP in arms
Rationale
Chronic mesenteric ischaemia: 2 of 3 major visceral arteries need to be
stenosed before pt develops chronic mesenteric arterial insufficiency as there is a
very good blood supply by celiac axis, superior and inferior mesenteric arteries.
Severe central abdo pain within 15mins of eating; food avoidance; ?diarrhoea.
Acute mesenteric ischaemia: surgical emergency; pt has pain, shock, bloody
diarrhoea, profound metabolic acidosis
Increased risk if smoke or hypertensive; most pts are asymptomatic until
aneurysm ruptures though may present with abdo/back pain(suggests renal colic
but a 60yo man with ‘renal colic’ has a AAA until proved otherwise by ultrasound),
shock and pulsatile mass; aorta bifurcates at L4/5(belly button): can palpate a
AAA here. Acute rupture may present as sudden death in a previously
asymptomatic individual.
Thoracic aneurysms: usually asymptomatic. Large ones may cause compression
symptoms : dysphagia, stridor, compression of the Superior Vena Cava ( SVC ).
May result in aortic incompetence; may cause angina due to encroachment on
coronary artery orifices. Rupture, with sudden death is a common occurrence.
Dissecting aneurysm: most commonly of the ascending aorta, presents with a
very severe, tearing sort of pain in the chest, neck, arms and BACK. Pulses may
be weak and BP may be low in the right arm. Initially the patient may be suspected
of having a heart attack.
D. Vasospastic symptoms
PC
Rationale
Raynaud’s
Intermittent digital ischaemia induced by cold and emotion; has 3 stages:
Pallor: due to digital artery spasm and/or obstruction
phenomena
Cyanosis: due to deoxygenation of static venous blood (fingers may feel cold, numb, tingling)
Redness and painful: due to reactive hyperaemia (with intense tingling in fingers)
Acrocyanosis
Usually bilateral but may be unilateral; may affect both hands and feet; may be primary (Raynaud’s
disease): idiopathic digital artery vasospasm; or secondary(Raynaud’s syndrome):
 Manifestation of a collagen disease : scleroderma, SLE,
 Rheumatoid disease, dermatomyositis
 May be associated with occupational trauma : chain saw operators, pneumatic hammer
operators, pianists.
 Thoracic outlet compression – often unilateral - ? Cervical rib
Cold, blue extremities ( not intermittent) worse during the cold weather, usually in young women –
cause not known
WEEK 16: Peripheral vascular system - Examination
Perform an arterial vascular examination
Introduction:
Intro, confirm pt, explain and gain consent
General inspection:
Pt well at rest?
Around bed: mobility aids, meds, cigs, O2
Pt: age, signs of HF, cyanosis or pallor
Unlikely to do be asked to do – ‘please begin at the abdomen’
Hands:
Temp, clubbing (liver failure = low vit K), peripheral cyanosis (Raynaud’s), CREST, tar staining, cap refill, tendon
xanthoma, radial pulse, brachial pulse, carotid pulse, BP in both arms
Radial
Allen’s Test:
Ulnar
Radio-radio delay: coarctation of aorta
Brachial
Carotid
Note that carotid sinus massage provokes decrease in HR so be gentle if pt has
had TIA/stroke/stenosis/carotid sinus disease
Face:
Xanthelasma, corneal arcus, conjunctival pallor, chronic anaemia?, hydration status
JVP/prominent veins in neck or chest
Axiallary/subclavian vein occlusion
Horner’s syndrome
Carotid artery dissection or aneurysm
Hoarse voice
Thoracic aorta aneurysm
Abdomen inspection:
Obvious pulsations, masses, scars, mottling/ discolouration to abdomen (ruptured AAA)
Abdomen palpation: check for pain first
 Pulsatile mass: is the AA present? Press midline above umbilicus with one hand
 Expansile mass: if pulsatile mass found, is it expansile? Press deeply with both hands either side
Place palmar surface of 4 fingers either side of umbilicus, quite near the flanks and work your way into the umbilicus
feeling for an expansile mass. If find one, measure distance between fingers on skin surface. Is it tender too?
Leg inspection: compare both legs
 Dressings
 Discolourations – blue, brown, red
 Skin – dry, hair loss,
 Scars - LSV harvest, groin incision
 Swelling/ oedema
 Missing hair, nails (or changes), toes
 Ulcers/ non-healing injuries around pressure points
 Muscle wasting
 Ask pt to wiggle toes (checks for motor dysfunction in acute PAD)
 Look in between toes and lift up feet
1. Acute PAD:

Skin will appear blue/marble white, progressing to
dark purple (and not blanching) and gangrene
(black)
Leg palpation: work distal to proximal, check for pain
2. Chronic PAD:

Cold/numb sensation of extremities

Smooth, shiny, dry skin with no hair on legs

Thickened/brittle toenails (trophic changes)

Pale/blue foot

Pallor when extremity raised

Delayed capillary filling

Diminished/absent pedal pulses

Small, circular, painful ulcers over bony
prominences

Atherosclerosis is main cause (hence RF=age,
males, smoking, DM, hyperlipidaemia, hypertension)

+ve Buerger’s test; ankle BP <50mmHg




1.
2.
3.
4.
5.
Temp: compare both legs using back of hands
Sensation: ask pt to close their eyes whilst testing
Cap refill: hold for 5s and release; refill normal in <2s
Pulses: normal/ reduced/ absent: compare one side to the other
o Femoral: mid-point of inguinal ligament (ASIS to pubic tubercle)
o Popliteal: flex knee; diffuse feeling
o Radio-radio and radio-femoral delay
Allen Test
Identify both radial and ulnar pulses and apply pressure simultaneously in order to occlude the arteries.
The patient should clench and unclench the hand until the palm goes pale.
Release pressure from the ulnar artery and observe for the distinct pink colouration (reactive hyperaemia) of the palm.
If the recolouration of the palm is ≤ 5 seconds, then the circulation to the hand via the ulnar artery is adequate
The procedure can then be repeated to check the patency of the radial artery by releasing the radial artery first
Auscultation:
 Femoral bruits
 Aortic bruits
 Renal bruits
 Carotid bruits; if carotid bruits found – think of neurological assessment and fundoscopy
To finish:
 Thanks pt, ask if they have questions, allow them to redress in private, ?further tests and investigations
 Blood tests: FBC (anaemia); U and E (renal failure); fasting lipid profile; glucose (DM)
 Buerger’s test: With the patient lying supine, stand at the foot of the bed. Ask about pain. Raise both legs to 45°.
Hold for a minute. Ask the patient to sit up and swing the legs over the edge of the bed.
o A positive Buergers Test indicates critical limb ischaemia and the following signs will be elicited:
o When the legs are elevated there is extreme pallor of the sole of the foot develops along with
emptying (or ‘guttering’) of the superficial veins eg dorsal foot veins. Normally the veins will still hold
blood and so you can still compress them with your finger.
o Within 2-3 minutes of the legs becoming dependent the foot will turn from a bluish colour (as
deoxygenated blood refills the veins) to a deep red (‘sunset foot’) due to reactive hyperaemia (from
post-hypoxic vasodilation).
 ABPI:
 Duplex US: assess whether angioplasty may be of benefit
Perform a venous vascular examination: DVT
Introduction:
Intro, confirm pt, explain and gain consent
General inspection:
Pt well at rest?
Around bed: mobility aids, meds, cigs, O2
Pt: fractures, signs of surgery or injury, pregnancy,
Leg inspection: compare both legs
Redness
Swelling and pitting oedema
Varicose veins
Ulceration
Missing digits
Leg palpation: work distal to proximal
Temp
Tenderness
Pitting oedema
Pulses (as for arterial)
Measure:
Using measuring tape, measure mid-calf 10cm below tibial tuberosity comparing both legs at the same point; if >3cm
difference, then this is significant for a DVT
Auscultation:
Lung bases (for any signs of a PE = reduced breath sounds)
To finish:
Thank pt, cover him up, mention investigations
DD:
Cellulitis, ruptured Baker’s cyst, lymphoedema, compartment syndrome
Investigations:
Well’s score: if low, do D-dimer
Bloods: FBC, U and E, Clotting
Duplex scanning (Doppler and USS)
Venogram?
Perform a venous vascular examination: varicose veins
Introduction:
Intro, confirm pt, explain and gain consent
General inspection: pt is supine
Front of thigh to medial aspect: caused by long saphenous vein
Back of knee to lateral malleolus: causes by short saphenous vein
Look for: asymmetry, swelling, scars, pigmentation (brown haemosiderin), lipodermatosclerosis,
Instructions to pt:
Do you have any difficulty standing?
Can you please stand for me with your legs uncovered? = makes varicosities more prominent
Re-inspect leg
Palpation:
Gently press on them and watch them refill (confirms they are vascular)
Hard veins = thrombosis
Painful veins = phlebitis
Use back of hand to feel around varicosities, as they are normally warm
Special Tests: Trendelenburg’s test (SFJ is located 2cm inferior and 2cm medial to femoral pulse)
This tests for level of incompetence in veins
1. Ask patient to sit on edge of examination couch. Check for pain
2. Elevate the limb as far as is comfortable for the patient and empty the superficial veins by ‘milking’ the leg.
3. With the leg still elevated exert digital pressure (or apply a tourniquet) over the saphenofemoral junction. (2-3cm
below and 2-3cm lateral to the pubic tubercle)
4. Ask the patient to stand
5. if varicosities refill then the incompetent vein is lower eg in the presence of saphenofemoral junction incompetence
the varicose veins will not refill until the digital pressure (or tourniquet) is removed.
Special Tests: Morrisey’s/ Cough test
Ask pt to stand
Place fingers over SFJ and ask them to cough
If a thrill is felt, it suggests incompetence


Pratt’s Test: Occlude SFJ, bandage legs, slowly unravel and look for level of incompetent perforators
Tap (Schwartz’) Test: pt stands, one hand on SFJ, one hand on varicosities, tap SFJ and feel for thrill in other
hand. If thrill present – backflow between SFJ and varicosities
Special Tests: Doppler US probe test:
Place a Doppler at the SFJ
Squeeze the calf
Normal leg produces a single Doppler ‘whoosh’ as blood goes back to the heart
A leg with incompetent veins will give a second ‘whoosh’ as you stop squeezing when blood flows backwards ino the
veins
Can repeat at the saphenopopliteal junction
To finish:
Thank pt, cover them up, mention any investigations, check peripheral pulses, PR exam (ovarian tumour), history
Combined venous vascular examination:
Introduction:
Intro, confirm pt, explain and gain consent
General inspection: pt is supine
Pt well at rest?
Around bed: mobility aids, meds, cigs, O2
Pt: fractures, signs of surgery or injury, pregnancy,
Front of thigh to medial aspect: caused by long saphenous vein
Back of knee to lateral malleolus: causes by short saphenous vein
Look for: asymmetry, swelling, scars, pigmentation (brown haemosiderin), lipodermatosclerosis,
Unlikely to do be asked to do – ‘please begin at the legs’
Hands:
Temp, clubbing (liver failure = low vit K), peripheral cyanosis (Raynaud’s), CREST, tar staining, cap refill, tendon
xanthoma, radial pulse, brachial pulse, carotid pulse, BP in both arms
Radial
Allen’s Test:
Ulnar
Radio-radio delay: coarctation of aorta
Face:
Xanthelasma, corneal arcus, conjunctival pallor, chronic anaemia?, hydration status
JVP/prominent veins in neck or chest
Axiallary/subclavian vein occlusion
Horner’s syndrome
Carotid artery dissection or aneurysm
Hoarse voice
Thoracic aorta aneurysm
Leg inspection: compare both legs
 Dressings
 Discolourations – blue, brown, red
 Skin – lipodermatosclerosis,
 Scars - LSV harvest, groin incision
 Swelling/ oedema
 Nails changes or missing toes
 Varicosities
 Ulcers
 Muscle wasting
 Look in between toes and lift up feet
1. Varicose veins:
 Normal pulses
 Brown patches of discolouration on lower legs
 Oedema/swelling
 Irregularly shaped, painless ulcers on ankles – may lead to varicose
eczema(stasis dermatitis)
 Cyanosis and pain at rest
 Pain relief when legs elevated – assists venous return
 No intermittent claudication
 Normal nails
 Warm
 Lipodermatosclerosis (skin hardness from subcut fibrosis caused by chronic
inflammation and fat necrosis) = inverse champagne bottle appearance
2. DVT:
 Unilateral swelling distal to the
site
 Unilateral tenderness
 Unilateral leg pain
 Warmth
 Discolouration – red
 Homan sign in 10% pts –
discomfort in calf during gentle,
forced dorsiflexion of foot
 RF – female, the pill, bed rest,
obesity, long haul flights,
fractures of lower extremity
Instructions to pt:
Do you have any difficulty standing?
Can you please stand for me with your legs uncovered? = makes varicosities more prominent
Re-inspect leg
Palpation:
Gently press on them and watch them refill (confirms they are vascular)
Hard veins = thrombosis
Painful veins = phlebitis
Use back of hand to feel around varicosities, as they are normally warm
Temp
Tenderness
Pitting oedema
Pulses (as for arterial)
Measure:
Using measuring tape, measure mid-calf 10cm below tibial tuberosity comparing both legs at the same point; if >3cm
difference, then this is significant for a DVT
Auscultation:
Lung bases (for any signs of a PE = reduced breath sounds)
Special Tests: Trendelenburg’s test (SFJ is located 2cm inferior and 2cm medial to femoral pulse)
This tests for level of incompetence in veins
6. Ask patient to sit on edge of examination couch. Check for pain
7. Elevate the limb as far as is comfortable for the patient and empty the superficial veins by ‘milking’ the leg.
8. With the leg still elevated exert digital pressure (or apply a tourniquet) over the saphenofemoral junction. (2-3cm
below and 2-3cm lateral to the pubic tubercle)
9. Ask the patient to stand
10. if varicosities refill then the incompetent vein is lower eg in the presence of saphenofemoral junction incompetence
the varicose veins will not refill until the digital pressure (or tourniquet) is removed.
Special Tests: Morrisey’s/ Cough test
Ask pt to stand
Place fingers over SFJ and ask them to cough
If a thrill is felt, it suggests incompetence


Pratt’s Test: Occlude SFJ, bandage legs, slowly unravel and look for level of incompetent perforators
Tap (Schwartz’) Test: pt stands, one hand on SFJ, one hand on varicosities, tap SFJ and feel for thrill in other
hand. If thrill present – backflow between SFJ and varicosities
Special Tests: Doppler US probe test:
Place a Doppler at the SFJ
Squeeze the calf
Normal leg produces a single Doppler ‘whoosh’ as blood goes back to the heart
A leg with incompetent veins will give a second ‘whoosh’ as you stop squeezing when blood flows backwards ino the
veins
Can repeat at the saphenopopliteal junction
To finish:
Thank pt, cover them up, mention any investigations, check peripheral pulses, PR exam (ovarian tumour), history
1. Ankle: Brachial Pressure Index (ABPI): to exclude PAD
ABPI is measured using a hand-held Doppler and a sphygmomanometer.
1. The patient must be rested in the supine position or ankles raised to the same height as the heart.
2. The systolic pressure is measured in the dorsalis pedis and posterior tibial arteries of the same leg by holding the
Doppler probe over the pedal artery while a blood pressure cuff wrapped around the ankle is inflated.
3. The pressure at which the Doppler signal disappears gives the systolic pressure in that artery (or re-appears when
pressure released THINK! Just like taking a BP and Korotkoff sounds appear).
4. The blood pressure should be taken in both arms and the ABPI is calculated as follows:
ABPI
=
Highest ankle systolic pressure
Highest brachial systolic pressure
sBP(leg)
sBP(arm)
A value for ABPI can be obtained for each leg. Normally the systolic BP in legs ≥ arms so a normal ABPI should be ≥1
in the supine position. ABPI is a sensitive marker of arterial insufficiency. Typical values of ABPI are:
>1.3
= Calcification due to DM or atherosclerosis
0.9-1.3 = Normal
0.8 = 20% mortality in 10 years
0.6-0.9 = Mild-mod claudication
0.4 = 80% mortality in 10 years
0.3-0.6 = Severe claduication
<0.3
= Critical ischaemia and renal problems
N.B. In diabetics the systolic BP in the lower limbs is sometimes not measurable as the arteries are calcified and
difficult to compress leading to a falsely raised ankle pressure (possibly giving false normal result).
Pole test can be used in this case – foot is raised slowly whilst auscultating pedal pulses and systolic BP value is read
from a specially calibrated pole at the level where pulse disappears.
2. Handheld Doppler US – investigate bypass grafts
Uses the Doppler effect. Triphasic flow = normal artery; monophasic = past a stenotic area
 Triphasic:
o Phase one - During systole, blood flow accelerates in a forward direction within the blood vessel.
o Phase two - A drop in peak systolic pressure leads to a reverse flow of blood within the blood vessel.
o Phase Three - Elastic recoil of the vessel at the end of diastole leads to a further forward flow of blood
in the vessel.
 Biphasic:
o Vessels naturally lose their elasticity as part of the ageing process, making the signal biphasic.
 Monophasic:
o Monophasic signal produces only one sound and usually denotes vessel disease. The sound heard is
usually lower in pitch.
3. MRA – investigate deep arteries of leg
Take image before and after contrast agent and build up an arterial map of body
4. CT scan – exclude AAA
Can give dye – arteries appear white
5. Catheter angiography
Small tube into artery with wire in which you can inject X-ray contrast down it; have to do so over a bony prominence
do can put pressure over it for 10mins after to stop bleeding; then do digital subtraction where –ve and +ve images
subtracted from each other showing only the images of the lumen of the vessel
Examining a patient with Peripheral Vascular Disease
Case to illustrate:
Presenting complaint:
Students:
past medical history
PAINFUL LIMBS (ischaemic limb)
Pamela Valerie Davies, a 56-year-old lady who is overweight, presents to her
GP with a painful, cold right leg.
How do you approach this?
You should concentrate on the history of the presenting complaint: painful cold
limb. Associated features. The characteristics are:
- the pain started 3 months ago and has been getting worse
- the calf feels tight and painful whilst walking and was relieved entirely by
resting for approximately 10mins
- Previously, it would return when she walked again, after about 200m
- However, today the leg suddenly became very painful and cold. nothing
makes it better.
- she has had no previous pain in either limb
WHAT OTHER FEATURES IN THE HISTORY SHOULD YOU ASK ABOUT?
- hypertension; non-insulin dependent diabetes mellitus
family history
- mother & father died from heart disease, both in their 60s; younger brother,
in his 50s, has angina
drug history
-
atenolol, glibenclamide
allergies
-
none known
review of systems
-
CVS: no specific features
RS: no specific features
GIT: no specific features
GU: no specific features
CNS: no specific features
Locomotor: no specific features
social history
Comment:
- housewife, limited mobility due to obesity
- alcohol: none
- smoking: 15 cigarettes per day
This patient has presented with an intermittent claudication. She has a number
of predisposing factors for limb ischaemia, eg hypertension, diabetes mellitus,
family history and smoking. The discussion with the students should include
risk factors and the preventative measures that can be taken.
Features on examination of this patient which could be discussed and which would be evident if you examined such a
patient on the ward after admission include:
-
cold, pale foot
-
the presence or absence of pulses
-
the use of the Doppler probe
Specific examination features for students to practise:
examination of peripheral pulses
changes due to poor arterial flow
examination of venous system
examination with a Doppler probe
PULSES AND BRUITS
Clinical Features of Venous and Arterial Ulceration
PMH
Cause
Location
Base
Edge
Arterial
Smoker, ID, PVD, DM
Venous
Varicose veins, DVT
Arterial ischaemia
Distal foot, tips of
toes, heels, bony
prominences
Dry,
necrotic,
gangrenous base with
little/no evidence of
healing
Punched out
Venous hypertension
‘Gaiter area’ = maleoli and
lower calf, predominantly
medial malleolus
Active evidence of chronic
granulation, bleeds,
Sensation
Skin
Painful
Pale, poorly diffused,
previous amputations
CRT
Prolonged
Shallow or sloping
irregular healing edge
Normal
Haemosiderrin,
lipodermatosclerosis,
shiny/tight
Normal
with
Friable base that may
extend deeply into the
tissues
and
expose
tendons or bones
Punched out
Marjolin’s
Long
standing
ulceration
Malignant change
Anywhere at site of
previous
ulcer,
usually venous
Irregular areas of
cellulitis or wet
gangrene
appearance
Irregular
Insensitive
Callous formation
Satellite lesions
Normal
Normal
Neuropathic
DM,
peripheral
neuropathy, burning pain
Loss of sensation
Pressure areas, base of
feet, 4th and 5th MTPJ