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 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
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