PVD history and examination

Question 1

What is a history of intermittent claudication like?

Answer 1

S - depends on site of arterial occlusion
O - acute (after acute thrombosis), chronic (artherosclerotic stenosis/occlusion)
C - gripping, cramping, burning, tightness
R
T - intermittent
E - exercise
R - rest
S

Question 2

What is a history of rest pain like?

Answer 2

S - foot/toes
O - usually progresses from intermittent claudication to rest pain
C - sharp, burning
R
A - chest pain, may suggest atherosclerotic vascular disease elsewhere eg IHD, cerebrovascular disease, erectile dysfunction
T - worse at night
E - elevation of leg
R - lowering of leg

Question 3

What are the signs and symptoms of acute ischaemia?

Answer 3

6Ps

• Pain
• Pallor
• Paraesthesia
• Perishingly cold
• Pulselessness
• Paralysis

Question 4

How does an AAA present?

Answer 4

Asymptomatic
Symptomatic - back pain
Ruptured - emergency with back pain and collapse

Question 5

How does a DVT present?

Answer 5

Pain, aching
Tenderness
Swelling
Increased warmth to touch
Altered skin colour

Question 6

What is Virchow’s triad?

Answer 6

Factors predisposing you to venous thrombosis

• Stasis
• Hypercoagulability
• Intimitial damage

Question 7

What should you ask about in PMH?

Answer 7

Previous vascular problems
Previous vascular surgery/intervention
Diseases caused by atheroma elsewhere
Risk factors - smoking, hypercholesterolaemia, DM, hypertension

Question 8

What should you ask about in the DHx?

Answer 8

Anticoagulants
Anti-platelets
Lipid/cholesterol lowering drugs
Cardiac medication
Anti-hypertensives
Oral contraceptive

Question 9

What should you ask about in social history?

Answer 9

Occupation
Smoking (pack years)
Alcohol
Diet
Exercise
Recent travel

Question 10

What should you ask about in family history?

Answer 10

Prothrombotic conditions that are hereditary eg Factor V Leiden mutation
Atherosclerosis

Question 11

What are the steps of a peripheral vascular examination?

Answer 11

Inspection
Palpation
Auscultation
Special tests

Question 12

What should you inspect?

Answer 12

Patient
Hands
Eyes
Lips and tongue
Abdomen
Legs

Question 13

What should you look for when inspecting the patient?

Answer 13

Colour
Build
Comfort
Position

Question 14

What should you look for in the hands?

Answer 14

Colour
Capillary refill
Nicotine staining

Question 15

What should you look for in the eyes?

Answer 15

Subconjunctival pallor

Corneal arcus

Question 16

What should you look for in the abdomen?

Answer 16

Scars
Visible masses
Visible pulsation

Question 17

What should you look for in the legs?

Answer 17

Symmetry
Colour
Scars
Oedema
Trophic changes - loss of hair, shiny skin, wasting of subcutaneous tissues
Ulceration
CRT

Question 18

What should you palpate?

Answer 18

Pulses
Checking light touch sensation
BP in both arms

Question 19

What pulses should you palpate?

Answer 19

Radial - compare
Ulnar
Brachial
Allen's test
Carotids
Aorta
Femoral 
Popliteal
Dorsalis pedis
Posterior tibial

Question 20

What should you auscultate?

Answer 20

Carotids
Subclavian
Aorta
Femoral

Question 21

What should you assess for in the pulses?

Answer 21

Radial - rate, rhythm, volume, radio-radial delay
Ulnar - volume
Brachial - volume and character
Carotid - character and volume

Question 22

What special tests should you do in a PVD exam?

Answer 22

Assess power in foot/leg
Buerger’s test
ABPI

Question 23

How do you do Buerger’s test?

Answer 23

With patient supine elevate both legs to 45 and hold for 1-2 mins
Pallor of feet indicates ischaemia
Poorer the arterial supply, the less the angle to which the legs have to be raised for them to become pale (Buerger’s angle)
Sit patient up and ask them to hand their legs down over the side of the bed at 90
Gravity aids blood flow and colour returns to ischaemic leg
Skin goes from blue - red