• Presenting complaints arterial disease or venous disorders will be different
• However, some general points:

1. DM
2. HT/ other heart disease
3. Clotting disorders - known or suspected, taking anticoagulant drugs
4. Fam Hx CVD
5. Smoking
6. Details of prev Tx

Commonest symptoms: due to partial/ complete interruption of BF in artery

Depending on suddenness/ degree of obstruction:

SYMPTOMS: ischaemia

SIGNS: reduced skin perfusion, absent flow, turbulent flow

DIAG: BV's

• No aorta below umbilicus
• Internal iliac: bowel, bladder, uterus, reproductive organs
• External iliac: becomes femoral artery at groin
• Common femoral divides into superficial and profunda
• Deep: m's of thigh
• Superficial femoral artery: rest of leg, most commonly obstructed - adductor hiatus - popliteal a at back of knee
• Divides into anterior tibial - dorsal pedis
• Posterior tibial - medial side foot
• Peroneal - bet 2 bones (interosseous membrane)
• Pulses: femoral, popliteal, dorsalis pedis (dorsum foot), posterior tibial (medial)
• Arterial obstructive disease most common in LL

• Does Pt have arterial occlusive disease?
• Is occlusion acute or chronic?

1. Acute: 6 P's - pain, numbness (paraesthesia), pale, paralysed (if prolonged), perishing (with cold), pulseless
2. Chronic: most ischaemia seen

• How severe? Bad = limb threatening (if nothing done, lose limb in wk-mth)
• Where is occlusion? Determine Tx - eg. Bypass
• Why?

1. Age
2. Sex
3. Occupation: eg. bad leg may affect occupation
4. Past health + meds

Symptom

1. Intermittent claudication: pain on walking (eg. Thigh m's, calf m's); fine at rest, once PA blood supply cannot meet demand (pain, tired); know claudication distance; pain aggravated by walking + relieved by rest; pain never at rest

1. Pain never occur at rest
2. Pain only after a certain amount of exercise
3. Calf muscles are affected first, then the thighs
4. Pain goes away with rest
5. Pain returns with same amount of exercise

1. Rest pain: threaten viability of leg at rest, basal metabolic conditions not met (a new symptom, NOT a severe form of claudication); affects skin + subcutaneous (less supply, further away from central blood supply); pain at tip of foot (lowest BP, furthest from blood supply - does NOT occur at calf b/c not claudication); pain with sleep (supine, less gravity to pull on blood for perfusion, Pt hangs leg off side of bed)
2. Gangrene/ ulcers: breakdown of skin, terminal digits

Note: intermittent claudication NOT limb-threatening; rest pain + gangrene/ ulcers ARE limb-threatening

Risk factors for AS

1. Smoking: when did Pt stop?
2. DM: how long meds/ insulin injection (DM more severe)
3. HT: what meds, how many, how long (severity of comorbidity)
4. Hyperlipidaemia
5. Family Hx

1. IHD: angina pectoris, previous MI
2. Stroke

AS is a systemic disease

HX

• Mr Wong, a 70 yo retired night-watchman, presented with gangrene of his left fifth toe for 3m
• The gangrene was spontaneous and progressed from the tip of the toe without trauma
• He also suffers from intermittent claudication affecting his L calf, not the thigh, for 3m and this limits his activity to 100m (claudication distance)
• No other history of ulcer
• Severe resting pain of left foot worse at night and disturbs his sleep (severity of pain)
• He is a chronic smoker, consumes 20 cigarettes a day for 50y
• On Meds for DM and HT; has mild IHD but no family Hx of stroke or HT

P/E

• On physical examination, Mr. Wong is in good general condition. He walks without aid and is able to get on the couch himself.
• There is no pallor, jaundice, cyanosis or lymphadenopathy.
• His upper limb pulses were normal. His radial pulse was 70/min, regular and equal on both sides.
• His carotid pulses were normal.
• No bruit on neck
• On exam of his lower limbs, there was dry gangrene over his left fifth toe.
• No atrophy of calf muscles and no visible signs of trophic changes.
• No other ulcers
• No colour changes
• The temperature was slightly diminished on his left foot.
• Examination of his peripheral pulses showed normal femoral pulse on both sides, but absent left popliteal and distal pulses. On the right side the popliteal pulses was normal but the distal pulses were diminished.
• No bruits were heard in the femoral and iliac regions and no abdominal bruits.
• In conclusion, MR Wong is a 70 years old chronic smoker with DM and HT. He suffers from atherosclerotic occlusive disease of the superficial femoral artery with severe distal ischaemia leading to gangrene toe.
• Conclusion

1. Arterial obstructive disease
2. Chronic
3. Bad: gangrene
4. Occlusion: L superficial femoral a
5. Why? Smokes, HT, fam Hx

1. General state: may Pt's old, frail
2. Ambulation/ gait
3. P, J, C

Most imp clinical evidence of artery normality = feel normal pulse?

Locate all "major" pulses + record their palpability.

• Limb exposed at room temperature

• Palpation

1. Temperature (differences) - use back of hand [Palpation from end of bed - can compare L+R]
2. Sensory + motor function
3. Pulses

Venous refill time - "full" subcut vein emptied (stroking finger along it) in the direction of the heart - finger press released - vein immediately refills if the circ normal

Capillary refill time - more sensitive - digital press over skin causes blanching - rel: cap refill immediately, colour returns promptly ("delayed" capillary refilling = abn)

1. Palpation: ab (AAA)
2. Auscultation: bruits (esp. femoral a, also iliac, aortic at umbilicus)

Bruits: iliac artery, femoral artery, carotid

Usually don't need to take BP, but MUST MENTION in exam

• Superficial

1. Prominent, tortuous, dilated, leg veins (varicose)
2. Pain - varying, distension of veins to more severe (thrombophlebitis)
3. Bleeding - profuse if large distended "varix" injured

• Perforating: connect superficial and deep
• Deep veins: to deep fascia

1. Pain - deep vein blockage by thrombus
2. Swelling (pitting" oedema)
3. Venous ulceration if blockage unrelieved

Occlusion + valvular incompetence can occur in any

Great saphenous: inside of foot - front of medial malleolus (cf. artery - at back of medial malleolus) - curves on medial side to saphenous opening / sapheno-femoral junction at groin (where superficial vein of long saphenous penetrates fascia and joints common femoral vein - 2cm below and lateral to pubic tubercle - more medial than artery). 90% of varicose veins are long/ greater saphenous vein

Perforating: lower, middle, upper calf perforators (medial leg - usu. hands-breadth apart) - the most constant. Most perforators connected to tributaries of vein (not main axis of vein)

PHYSICAL EXAM

• Ask Pt to stand-up, exposure both legs
• Pt lying down then standing - varicose veins "back-filled" with blood (valvular incompetence)
• Describe: long saphenous system is distended
• Varicosities - degree, distribution (Pt standing) - ID site (level) of valvular incompetence (Trendelenberg) - Doppler examination more accurate
• Swelling (oedema)
• Redness over vein - inflam (thrombophlebtis)
• Ulceration - describe (site, edge, base, etc.)
• Pigmentation
• Oedema - pitting, "brawny" (non-pitting) if chronic tenderness

• Easier to palpate than inspect veins
• Skin changes: ulceration, pigmentation
• Palpable thrill at sapheno-femoral incompetence (Pt cough, Valsalva manoeuvre - increase intra-ab pressure), or put fingers lower down on leg and tap at vein position - normally would not have transmission
• Sapheno-femoral valve is the first valve to go

Tourniquet examination (a test, NOT a sign) - Tredelenburg Test