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:
  • Abdominal Aorta - palpate for aneurism
  • 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

	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

Observed structured clinical examination

Acute Confusion - Acute Coronary Syndrome Orders - Anemia - Arterial Blood Gasses - Asthma - Blood Pressure - Chest pain - Chest XRay - CHF - Coma - COPD - Cranial Nerves - Diabetic History - Diabetic Foot - Dysphagia - EKGs - Gallbladder and Liver - Liver Disease - Gait and Balance - Headache - Hematemesis - Hypertension - Jugular Venous Pulses - Knee Exam - Lymph Nodes - Community Acquired Pneumonia - Parkinson Disease - Peripheral Arterial Insufficiency - Pneumonia Examination - Precordial Exam - STD's - Spleen - Swollen Leg Exam - Thyroid Exam - Upper vs Lower Motor Neuron Lesions - Urinary Incontinence