■ Intermittent claudication
■ Cold, numbness, pallor in the legs, hair loss
■ Color change in fingertips or toes in cold weather
■ Swelling in calves, legs, or feet
■ Swelling with redness or tenderness
To assess possible peripheral vascular disease, begin by asking patients about See Table 14-1, Painful Peripheral any pain in the arms and legs. Be aware that pain in the extremities may arise Vascular Disorders and Their from the skin, the peripheral vascular system, the musculoskeletal system, or Mimics, pp. 460-461. the nervous system. In addition, visceral pain may be referred to the ex-
tremities, like the pain of myocardial infarction that radiates to the left arm or cervical arthritis that radiates to the shoulder.
To elicit symptoms of arterial peripheral vascular disease in the legs, inquire about intermittent claudication, which is exercise-induced pain that is absent at rest, makes the patient stop exertion, and remits within about 10 minutes. Ask "Have you ever had any pain or cramping in your legs when you walk or exercise?" and "How far can you walk without stopping to rest?" Also, "Does the pain get better with rest?" These questions clarify what makes the patient stop and how quickly the pain is relieved. Ask also about coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces.
Atherosclerosis can cause symptomatic limb ischemia with exertion; distinguish this from spinal stenosis, which produces leg pain with exertion that may be reduced by leaning forward (stretching the spinal cord in the narrowed vertebral canal) and less readily relieved by rest.
Hair loss over the anterior tibiae in decreased arterial perfusion. "Dry" or brown-black ulcers from gangrene may ensue.
Many patients with arterial peripheral vascular disease have few symptoms, Only about 10% of affected paso it is important to identify background risk factors. Assess the patient's his- tients have the classic symptoms of tory of tobacco abuse. Ask if the patient has had hypertension, diabetes, or exertional calf pain relieved by rest. hyperlipidemia. Further, is there any history of myocardial infarction or stroke? Such patients warrant further evaluation, even if without symptoms in the extremities (see p. 448).
To elicit symptoms of arterial spasm in the fingers or toes, ask "Do your fingertips ever change color in cold weather or when you handle cold objects?" . . . "What color changes do you notice?" . . . "What about your toes?"
Digital ischemic changes of blanching, followed by cyanosis, then rubor with cold exposure and rewarming in Raynaud's phenomenon or disease
There may be symptoms of venous peripheral vascular disease, such as swelling of the feet and legs. Ask about any ulcers on the lower legs, often the near ankles.
Hyperpigmentation, edema, and possible cyanosis, especially when legs are dependent, in venous stasis ulcers
The redness, swelling, and tenderness of local inflammation are seen in some vascular disorders and in other conditions that mimic them. In contrast, relatively brief leg cramps that commonly occur at night in otherwise healthy people do not indicate a circulatory problem, and cold hands and feet are so common in healthy people that they have relatively little predictive value.
Inflammation in cellulitis, superficial thrombophlebitis, and erythema nodosum
Etiology of common leg cramps and "restless legs" not well understood. Leg cramps sometimes from diuretic use with hypokalemia
Important Topics for Health Promotion and Counseling
■ Detection of peripheral arterial disease (PAD)
■ Risk factors for PAD
■ Screening for PAD: the ankle-brachial index (ABI)
Peripheral arterial disease (PAD) generally refers to atherosclerotic occlusion of arteries in the lower extremities. The femoral and popliteal arteries are involved most commonly, followed by the tibial and peroneal arteries. PAD affects from 12% to 25% of community populations; however, recent studies* have shown that despite significant associations with cardiovascular and cerebrovascular disease, PAD often is underdiagnosed in office practices. Most patients with PAD have either no symptoms or a range of nonspecific leg symptoms, such as aching, cramping, numbness, or fatigue. The classic triad for vascular claudication, exercise-induced calf pain that causes stopping of exercise and results in relief of pain in 10 minutes or less, may be present in only about 10% of affected patients.*
Patients with current or past tobacco use, diabetes, hypertension, hyper-lipidemia, or cardiovascular or cerebrovascular disease are at increased risk of atherosclerotic PAD. Such patients should be screened for subclinical PAD and targeted for aggressive risk factor intervention. For screening, clinicians should consider use of the ankle-brachial index (ABI), a highly accurate test for detecting 50% or greater stenoses of 50% or more in major vessels of the legs. The ABI is readily performed by clinicians or office staff, and consists of measuring the systolic blood pressure with Doppler ultrasonography in each arm and in the dorsalis pedis and posterior tibial pulses. The ABI is calculated on both the right and left by dividing the higher right ankle pressure by the higher right arm pressure, and the higher left ankle pressure by the higher left arm pressure. ABI values are as follows: 0.90-1.30 is considered normal; 0.41-0.90—mild to moderate peripheral arterial disease, usually with symptoms of claudication; and 0.00-0.40—severe peripheral vascular disease with critical leg ischemia.
The severity of peripheral vascular disease closely parallels the risk of myocardial infarction, ischemic stroke, and death from vascular causes. Patients with ABIs in the lowest category have a 20% to 25% annual risk of death.* A wide range of interventions is available to reduce both onset and progres-
*Hirsh AT, Criqui MH, Treat-Jacobson D, et al: Peripheral Arterial Disease: Detection, Awareness, and Treatment in Primary Care. JAMA 286 (11):1317-1324, 2001; Hiatt WR: Medical Treatment of Peripheral Arterial Disease and Claudication. NEJM 344 (21):1608-1620, 2001.
sion of subclinical PAD, including meticulous foot care and well-fitting shoes, tobacco cessation, treatment of hyperlipidemia, optimal control and treatment of diabetes and hypertension, use of antiplatelet agents, and, if needed, surgical revascularization.
(Students should consult specialty texts for less common forms of vascular occlusion from arterial or venous thrombosis or endarteritis from infection, inflammation, or autoimmune disease.)
Preview: Recording the Physical Examination— The Peripheral Vascular System
Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination. Recall that the written description of lymph nodes appears after the Head and Neck section (see p.143). Likewise, assessment of the carotid pulse is recorded in the Cardiovascular section (see p. 265).
"Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric."
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