Peripheral Vascular

Case 3 – Pain in Legs

You are seeing Mr. Perera, a 68 year old male, in an outpatient clinic. He’s coming in today because he’s been getting pain in his legs for the last few months, and it’s getting worse. Please take a focused history of his complaint.

History

  • Onset and duration of pain
  • Quality of pain
  • Aggravating factors (pain is elicited by walking)
  • Distance travelled that elicits pain (2 blocks)
  • Alleviating factors
  • Intensity of pain
  • Radiation of pain
  • Pain at night
  • Neurologic symptoms, such as numbness or parasthesias
  • Leg trauma
  • Asks if both legs are affected (yes)
  • Foot ulceration
  • Lower limb infection
  • Shortness of breath
  • Recurrent chest pain
  • Personal history of myocardial infarction and stroke
  • Peripheral vascular disease
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Family history of cardiac or cerebrovascular events
  • Effect on daily activities

Case 2 – Limb Pain

You are seeing Ms. Richards, a 45 year old female, in the ER for a two day history of right leg pain. Please perform a focused history and physical examination.

History

  • Onset and duration of pain
  • Severity of pain
  • Location of pain
  • Alleviating and aggravating factors
  • History of trauma to leg
  • Leg swelling
  • Neurologic symptoms in affected limb
  • Association with shortness of breath
  • Fever
  • Diaphoresis
  • Chest pain
  • Hemoptysis
  • Personal history of clotting disorders
  • Personal history of malignancy
  • Pregnancy history
  • Use of hormone replacement or oral contraceptive pill (patient uses OCP)
  • History of immobilization
  • Recent leg trauma
  • Medications/Allergies
  • Smoking history (quantity in pack-years)
  • Family history of thromboembolic disease (DVTs, PEs)

Physical Examination

Inspection

  • Inspects for swelling, edema
  • Inspects for erythema and varicosity in affected limb
  • Inspects for venous ulcers in lower limbs
  • Inspects for joint effusions in affected limb

Palpation

  • Palpates affected lower limb for tenderness
  • Compares limbs for warmth
  • Measures and compares calf circumference for each limb
  • Assesses sensation in affected limb

Case 1 – Acute Paralysis

You are seeing Ms. Richards, a 75 year old female, in the ER. She is distraught because she is presenting with a two hour history of complete left leg paralysis. Please perform a focused history and physical examination.

History

  • Onset and duration of paralysis
  • Associated sensory loss
  • History of trauma to leg
  • Leg swelling
  • Pain in leg
  • Parasthesias in leg
  • Numbness in leg
  • Shortness of breath
  • Chest pain
  • Head trauma
  • Weakness elsewhere in the body
  • Sensory loss elsewhere in the body
  • Vision or speech changes
  • Personal history of myocardial infarction and stroke
  • Peripheral vascular disease
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Medications/Allergies
  • Family history of cardiac or cerebrovascular events

Physical Examination

Inspection

  • Comments on color of affected limb (pale)
  • Inspects for hair loss/lack of oil on affected limb
  • Inspects for arterial and diabetic ulcers on feet bilaterally (small ulcer on bottom of 1st toe)
  • Inspects for leg swelling

Palpation

  • Palpates affected limb for tenderness
  • Compares temperature in lower limbs
  • Assesses sensation in both lower limbs
  • Assesses power in both lower limbs
  • Assesses capillary refill in affected limb

Auscultation

  • Auscultates bilaterally for femoral and popliteal bruits
  • Auscultates abdomen for aortic aneurysm