Peripheral Artery Disease

Abstract

H ow best to approach a patient with peripheral arterial disease (PAD) can be an intimidating and confusing task. There are few disease processes as variable in location, presentation, and severity as those seen in the vasculopath. There are many etiologies to be considered simultaneously. Ironically, it is the variability of PAD that provides an opportunity to extract a comprehensive and tightly integrated history and physical examination that is nearly unparalleled in medicine. Similarly, there are few disease processes that offer the opportunity to impact so many aspects of the patient, literally from head to toe. This article, part of a series on PAD, focuses on the initial assessment and evaluation of the PAD, with pathophysiology, genetics, and treatment addressed in accompanying articles. HistoryEach patient with PAD is unique (Table 1). Even though the pathophysiology, risk factors, location, and eventual treatment options for a patient often prove routine, the manner in which the patient presents is anything but predictable. 1 We have all had the experience of taking a well-structured history (Table 2) from a textbook patient, presented to an attending physician or a colleague, and then watched and listened in disbelief as the confirmatory history is nothing at all similar to what was heard 15 minutes earlier. Unfortunately, patients do not often read the textbook. As demonstrated by McDermott and colleagues, 2 the discomfort caused by PAD is more often atypical than typical. Descriptions such as "tired," "giving way," "sore," and "hurts" are offered more often than "cramp." This forces the healthcare provider to meticulously clarify the location, quality, and circumstances of the discomfort. It is not unusual that a patient reports ≥2 types and locations of discomfort. Careful consideration for pain from both orthopedic and neurogenic sources must be taken. Each symptom should be individually addressed and clarified. These symptoms must be taken in context with the lifestyle of each patient. Defining how the symptoms have an impact on vocation, activities of daily living, and social activities should be done with each evaluation. Comorbidities and risk factors for PAD are discussed elsewhere in this series and should be elicited from the patient when not already clear. The physical examination should focus on the clues gleaned from the history. Specific scenarios are discussed at the end of this article.