Peripheral Arterial Disease checklist

WIPPER and the Intro

• Introduce yourself and shake hands
  
• Washing of hands and appropriate hand hygiene
  
• Asking for permission
  
• Ensuring the room’s privacy
  
• Ensuring the environmental warmth and good lighting conditions
  
• Asking for appropriate exposure (from the waist and above and from the knees and down)
  
• Asking the patient to be in the appropriate position (semi-sitting at 45 degrees in bed)
  
• Relocating to the right side of the patient
  
• Asking for a chaperon
  
• “I have all of my equipment’s”

General Look of the Patient

• Consciousness, alertness and orientation of the patient to time, place and person (After asking the 3 questions)
  
• Comment on the patient’s position and comfort
  
• Comment on no obvious shortness of breath (PE)
  
• Comment on the patient’s external devices such as any mobility aids (Wheelchairs, walking aids)
  
• Comment on any Medical equipment’s such as any dressings or limb prosthesis
  
• Comment on cyanosis
  
• Comment on no limb pallor

Vital Signs (Mention)

• Mention measuring Blood pressure bilaterally
  
• Make sure you know the 6 vital signs

Inspection

• Inspect the upper limbs bilaterally and do not forget the hands and fingers
  
• Inspect the lower limbs bilaterally and do not forget the feet and toes, also check the back of the legs + sole
  
• Mention no missing limbs or digits, and no scars and no dressings
  
• Mention no xanthomata (Hyperlipidema is a major risk factor for PAD)
  
• Mention no Tar stain (Smoking is a major risk factor for PAD)
  
• Mention no muscle wasting
  
• Mention seeing no dry skin, no shiny skin, no hair loss, no thickened or brittle nails
  
• Mention no signs of infections such as fungal → between the toes
  
• Mention no color changes such as pallor or darker pigmented skin (Lipo-dermato-sclerosis)
  
• Mention no gangrene

Note

Gangrene definition
Gross description of a necrotic tissue with mummification and black discoloration.
Wet gangrene is infected, looks black and unclearly demarcated, needs emergent amputation for risk of sepsis.
Dry gangrene is not infected, dark and well demarcated.
Finger tip necrosis is a sign for Buerger’s disease aka thromboangiitis obliterans.

• Mention no ulcers
  
• Mention no guttering of veins

Note

Guttering of veins
In a warm room the veins of a normal foot are dilated and full of blood, even when the patient is lying horizontally.
In an ischaemic foot the veins collapse and sink below the skin surface to look like pale-blue gutters.

• Ask the patient to move his limbs and mention no paralysis

Palpation

• Do the usuals for palpation
  
• Generally and gently palpate the limbs for any tenderness or crepitus (Gas gangrene)
  
• Mention no tenderness or crepitus
  
• Palpate with the dorsum of your hand to check temperature of upper and lower limbs, check on 3 points per limb, bilateral limbs at a time, normally you should feel symmetrically warm limbs.
  
• Check capillary refill time by applying 5 seconds of pressure to a digit’s nail, then release, notice its returning to its normal color (Normally takes <3 seconds)

All Pulses (Compare right and left!)

• Radial pulse; using 3 fingers, lateral to flexor carpi radialis
  
• Check both radial pulses simultaneously to assess “Radio-radial delay”, a sign for aortic dissection
  
• Check radial and femoral pulses simultaneously to assess Radio-femoral delay, a sign for aortic coarctation (ONLY MENTION)
  
• Brachial pulse, using 2 fingers, assess the brachial pulse medial to the biceps tendon in antecubital fossa (Bilaterally)
  
• Using 2 fingers, gently assess the carotid pulse anterior to sternocleidomastoid near the jaw
  
• Check posterior tibial pulse (posterior to medial malleolus, 1/3 distance between medial malleolus and calcaneus | 1 cm behind, 1 cm below medial malleolus (Macleod))
  
• Check dorsalis pedis pulse (lateral to extensor hallucis longus, against navicular bone)
  
• Also mention popliteal pulse just in case :)

Special - Buerger’s Test

• With the patient lying supine, stand at the end of the bed and raise both of the patients’ legs to 45 degrees and keep them for 1-2 minutes observing the colors of them
  
• Ask the patient to sit on the edge of the bed with his legs hanging
  
• Notice how the legs first turn blue due to the passage of deoxygenated blood through the ischemic tissue then they will become red (Reactive hyperemia)

Note

Interpretation of Buerger’s Test
- In a healthy individual, the legs should remain pink even up to 90°.
- Development of pallor indicates inadequate perfusion against gravity.
- Record the angle of pallor (Buerger’s angle): the lower the angle, the more severe the disease.
- When sitting, legs may first appear blue (deoxygenated blood in ischemic tissue), then turn red (reactive hyperemia).
This indicates ischemia and correlates with delayed capillary filling.

Note

Capillary Filling Time
After elevating the legs, patients should be asked to sit up and dangle their feet over the side of the couch.
A normal leg and foot will remain a healthy pink colour, whereas an ischaemic leg slowly turns from white (after elevation) to pink and then takes on a suffused purple-red colour.
The time taken for the colour of the foot to change from white to pink is the capillary filling time, and depends upon the degree of arterial obstruction.
In severe ischaemia it may be as long as 15-30 seconds. A red-purple foot is indicative of severe ischaemia.

Auscultation

• Mention auscultating over the femoral and carotids and mention no bruit

Further Investigations and Theoretical Knowledge

• Examine bilateral blood pressure to assess any discrepancies between the two arms suggestive of aortic dissection
  
• Complete CVS exam
  
• Upper and lower neurological examination
  
• I want to test for thoracic outlet syndrome

Roos stress test

Roos Stress Test Position

Ask the patient to abduct his shoulders to 90 degrees, with maximal external rotation on.
Test is positive when patient can’t keep this for more than 3 minutes.

• Allen’s Test
  
• Raynaud’s
  
• Ankle brachial pressure index

Note

Ankle Brachial Pressure Index (ABPI)
It is a ratio between the blood pressure measured in the ankle and that measured in the brachial artery, used to assess lower limb perfusion.

• Left ABPI = (Highest pressure of either left Post. tibial artery or left dorsalis pedis) / (Highest brachial pressure (R/L))
  
• Right ABPI = (Highest pressure of either right Post. tibial artery or right dorsalis pedis) / (Highest brachial pressure (R/L))

Normal ranges:
- Normal → \(0.8 - 1.3\)
- Mild or moderate arterial disease → \(0.5 - 0.79\) (claudication)
- Severe arterial disease → \(<0.5\) (Rest pain, ulceration, gangrene → critical limb ischemia)
- Calcified vessels → \(>1.3\) (suggestive of DM, vasculitis, atherosclerosis → need duplex US/CT angio)