Chronic Peripheral Arterial Insufficiency

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Contents 1 Upper limb 1.1 Inspection 1.2 Palpation 1.3 Auscultation 1.4 Provocative Tests 2 Lower Limb 2.1 Inspection 2.2 Palpation 2.3 Auscultation 2.4 Provokative Tests 3 Arterial vs. Venous Insufficiency 4 Other OSCE modules

[edit] Upper limb

[edit] Inspection

• cyanosis/pallor
• hair loss
• shiny skin
• ulcerations
• dystrophic nails
• muscle wasting

[edit] 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

[edit] Auscultation

• bruits:
  • abdominal aorta
  • renal (both anterior and posteriorly)

[edit] 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

[edit] Lower Limb

[edit] Inspection

• same as UL: cyanosis/pallor, hair loss, shiny skin, ulcerations (especially on the heel), dystrophic nails
  • edema (pitting or non)

[edit] 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

[edit] Auscultation

• bruits:
  • femoral
  • popliteal

[edit] 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

[edit] 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

[edit] Other OSCE modules