View source for Chronic Peripheral Arterial Insufficiency

==Upper limb==
===Inspection===
*cyanosis/pallor
*hair loss
*shiny skin
*ulcerations
*dystrophic nails
*muscle wasting

===Palpation===
*measure the ''blood pressure''
*skin ''temperature'' (compare bilaterally)
*''capillary refill time''

*Pulses: 
**AA
**radial, ulnar
**brachial - in antecubital fossa, medial to biceps tendon

===Auscultation===
*bruits: 
**abdominal aorta
**renal (both anterior and posteriorly)
	
===Provocative Tests===

*'''Allen's Test''' for adequacy of circulation to hand
**occlude both the radial and ulnar arteries → patient to make fist 
**open hand → release ulnar artery → watch for reperfusion of the palm
***repeat above for radial artery

*'''Ankel to Brachial Index'''
*compares the palpated systolic BP in the arm to that of the ankle
*with patient supine, place the center of the bladder posterior and ~ 3 cm above the medial malleolus
**resting ABI < 1 is abnormal
**< 0.95 → significant narrowing of blood vessels in the legs, ↑ CV risk
**< 0.8 → intermittent claudication
**< 0.4 → claudication may occur at rest
**< 0.25 → severe limb-threatening PAD

==Lower Limb==
===Inspection===
*same as UL: cyanosis/pallor, hair loss, shiny skin, ulcerations (especially HEEL), dystrophic nails
**edema (pitting or non)

===Palpation===
*skin TEMPERATURE (compare bilaterally)
*Capillary refill time

*Pulses:
**'''femoral''' - midway between the pubis and ASIS
**'''popliteal''' - inferior lateral portion of the popliteal fossa (leg slightly flexed)
**'''posterior tibial''' - inferior posterior border of medial malleolus
**'''dorsalis pedis''' - upper 1/3 of dorsal foot, lateral to EHL

*'''Radial Femoral Delay'''
**coarctation of aorta

===Auscultation===
*bruits: 
**femoral
**popliteal

===Provokative Tests===

'''Bueger’s test'''
*raise legs to 45° x 1 min → max blanching of skin
*have patient sit with both legs dangling down
**pinkness should return in < '''10 s'''
*look for dusky rubor ('''reactive hyperemia''')

'''DeWeese’s test'''
*disappearance of previously palpable distal pulses after walking

==Arterial vs. Venous Insufficiency==

{|border="1" cellpadding="2" cellspacing="0"
|-
|
|Arterial Insufficiency
|Venous Insufficiency
|-
|Pain
|claudication
|-
|Pulses
|↓
|-
|Color
|pale, dusky red on dependency
|-
|Temp
|↓
|-
|Edema
|
|marked
|-
|Skin
|trophic skin chagnes, thick nails
|brown pigmentation around ankle, stasis dermatitis
|-
|Ulcers
|very painful
|non painful
|}

==Other OSCE modules==
{{OSCE2}}
[[Category:Medicine]][[Category:OSCE]]