Signs of peripheral vascular disease - pulselessness, paralysis, paraesthesia, pain, pallor Peripheral Vascular Disease History of intermittent claudication

Arterial ulcer Punched out ulcer edge Low exudate content Edema is uncommon Cold skin Pale skin Causes : Located distally, usually dorsum of the foot Pain especially at night when supine Peripheral arterial disease Hair loss occurs Pulse absent Atherosclerosis hyperlipidemia Angiography Venous ulcer Sloping ulcer edge Edema is common Warm skin Red skin Causes :

The University of Manchester | W.L. Gan | 2012

History of deep vein thrombosis, varicose Usually on the "gaiter" region of the legs High exudate content Mild pain relieved by elevation Hairs present

Chronic venous insufficiency

Intermittent claudication Investigations / tests :

Pulse present

Smoking, diabetes, hypertension, Ankle-brachial pressure index Treatment and management : Smoking cessation

Throbbing, heaviness, restless legs Valve incompetency DVT - deep venous insufficiency Investigations / tests : valve incompetency Duplex ultrasonography Compression stockings Direct contrast venography

Trendelenburg test - locate the level of Treatment and management : sclerotherapy, vein stripping Endovenous laser ablation, injection

Control of lipid profile, diabetes, hypertension Cilostazol, Pentoxifylline ( claudication )

Cyanosis / pallor Tar staining Capillary refill Radial pulse Xanthelasma Blood pressure

Peripheral arterial disease General Inspection

Corneal arcus Carotid pulse

Conjunctival pallor Central cyanosis Radio-radial delay

Erythema, swelling, Inspection

Deep vein thrombosis

ulcer, scar, amputation Measure mid-calf measuring tape Active cancer

Obvious pulsation, mass, scar Inspection - abdomen Palpation - abdomen Inspection - legs Pulsatile, expansile mass Scar Discolouration Amputation Pulses Temperature Sensation Capillary refill Auscultation Special test Hair distribution Palpation - legs

Radio-femoral delay pulses, capillary refill circumference using >3cm - significant Major surgery Pitting edema Low0

Palpation - temperature,

Ask the patient to stand up and look at the leg veins Inspection

Varicose veins

tenderness, pitting edema, and compare both legs Paralysis, immobilisation Local tenderness Entire swollen leg Calf swelling >3cm Moderate 1-2 pts Wells score ( 1 pt for each )

long, short saphenous veins varicosities and release, watch them refill Feel for temperature Hard - thrombosis Painful - phlebitis

* asymmetry, swelling, scar,

pigmentation, stasis eczema

lipodermatosclerosis Palpation - gently press on the

Ulcers

Gangrene Pulses

Fungal infection Motor function Dorsalis pedis Popliteal Posterior tibial

Location of sphenofemoral junction - 5cm medial and inferior to femoral pulse * mid-inguinal line btw for impulse at SFJ Percussion test ASIS and pubic symphysis Feel for cough impulse at SFJ Tap distally on VV, and feel Raise the patient's legs Trendelenburg test If VV do not refill, SFJ incompetency at lower level Place two fingers on SFJ

Femoral, aortic, renal, carotids Buerger test > 1.2 < 0.5 0.9 - 1.2 0.8 - 0.9 0.5 - 0.8 Ankle brachial pressure index Vessel sclerosis Normal Mild Moderate

Collateral superficial vein Alt Dx more likely -2 pts High 3 pts

The Fontaine Classification Stage I asymptomatic

Stage II intermittent claudication Stage IV necrosis / gangrene

Severe arterial disease

If VV do refill, incompetency DD : cellulitis, ruptured Baker's cyst, stand repeatedly on tip-toe Investigations - doppler USS probe injection sclerotherapy, Rx - compression stocking, endovenous laser ablation

Stage III rest pain / nocturnal pain Rx - stop smoking, treat diabetes,

Investigations - FBC, lipids, blood glucose U&E ( renal disease ), duplex imaging hypertension, antiplatelet ( aspirin ), percutaneous transluminal angioplasty

compartment syndrome compression stocking, IVC filters

Tourniquet test Perthes test - deep vein obs.

Investigations - D-dimer to exclude DVT, FBC, clotting, compression duplex USS

Apply tourniquet at mid-thigh pain and more prominent VV

Rx - LMWH, warfarin INR 2-3,