Symptoms

Intermittent Claudication

• Ischemic muscle pain that results from inadequate blood flow.
• Classic lesion described as a cramping pain that occurs with exercise and is relieved with rest.
• Patients describe it as tiredness or weakness in thighs or buttocks.
• 2 levels of disease: aortic and iliac disease=thigh/buttock claudication
  Femoral and popliteal disease=calf claudication
• Patients can be monitored by how far they can walk before onset of pain (usually in city blocks).
• Other common causes of leg pain: Sciatica, Spinal Stenosis, Diabetic Neuropathy, and Osteoarthritis of the hip.

Rest Pain

• Usually indicates more severe disease, pain is constant due to insufficient blood supply.
• Often seen in the foot, described as a burning pain, gets WORSE with ELEVATION.
• Occurs most often at night when patients are sleeping, relieved when patients gets up to walk around.
• Patients often compensate by sleeping with their feet hanging over the side of the bed.

Impotence

• Most commonly associated with thigh and buttock claudication, usually due to aortoiliac insufficiency.
• Also seen in hypogastric insufficiency.

TIA (transient ischemic attack)

• Focal or generalized neurological symptoms which last less than 24 hours.
• Symptoms: Speech, ocular, sensory, or motor.
• Transient monocular blindness = amaurosis fugax

Risk Factors

Smoking

• How many packs/day? How many years?
• One of the most important factors for peripheral vascular disease.

Diabetes

• Juvenile or adult onset?
• Insulin controlled or diet alone?

Hypertension

• Association with cardiac disease and abdominal aortic aneurysms.
• How long has the patient been hypertensive?
• List of medications the patient is on.

Deep Venous Thrombosis or Pulmonary Embolus

• History is important for future treatment options

Hyperlipdemia or Clotting Abnormality

• Patients have a higher incidence of peripheral vascular disease.

Physical Exam

Pulses

Mandatory pulse checks: Carotid, Radial, femoral, popliteal, dorsalis pedis, and posterior tibial

Pulse grading:

• O = Absent
• 1+ = Barely Palpable
• 2+ = Normal
• 3+ = Enlarged
• 4+ = Aneurysmal

Bruits

• Important to document over carotid and femoral

Inspect

• Look for pallor, cyanosis, rubor, ulceration, gangrene, atrophy, temperature, or varicosities.
• Trophic changes include hair loss, shiny skin, and thickened toenails.

Doppler

• Ankle/brachial index and blood pressure or each arm should be recorded in every vascular patient.

History and Physical Exam Form

History

1. Cardiac Disease? Angina? MI? arrhythmia?
2. Claudication? How Far? Rest Pain? Impotence?
3. TIA? Stroke?
4. Smoking? How long? What Medication?
5. Diabetes? How long? Insulin? How much?
6. Hypertension? How long? Meds?
7. Clotting abnormalities? DVT Pulmonary embolus?
8. Hyperlipdemia?

Physical Exam

1. Blood pressure: Right_________ Left___________
2. Pulses:
   • Carotid
   • Radial
   • Femoral
   • Popliteal
   • Dorsalis Pedis
   • Post. Tibial.
     Note any bruits
     
3. Cardiac exam
4. Inspection of extremities: Perfusion? Varicosities? Tropic changes? Skin Changes?
5. Ankle brachial Index Right___________ Left________________

Source:  Vascular Surgery for the House Officer, 2nd edition; Jon R. Cohen