Live Vascular Physical Exam Demonstrates Best Practices

The vascular physical examination is key to diagnosis and care. At ISET 2019, a patient volunteer from Miami Cardiac and Vascular Institute underwent a live vascular examination from Michael Jaff, DO, as panelists offered their comments.

The patient was a woman who had previously been treated for critical limb ischemia and had had a good outcome. However, she was returning now with recurrent symptoms. In response to Dr. Jaff’s questions, the patient explained that about a year ago, she had come home from work and noticed pain in her toes. Her husband rushed her to Baptist urgent care where she was treated, after which the toe healed and the pain somewhat diminished.

In response to Dr. Jaff’s questions, the patient shared that she had a history of diabetes and resultant neuropathy in her feet. Her kidneys were not affected by the diabetes, and her eyes had been somewhat affected and treated. The patient then explained that she had started to experience pain in her calf in summer 2018. Dr. Jaff asked her a question about the nature of the pain, and she described it as a tightness. Dr. Jaff continued to probe the extent of her pain, asking the patient how often it occurred (every time she walks) and whether she could walk from the presentation room to the front of the hotel (she would need to stop and wait for about 30 minutes for pain to diminish).

Dr. Jaff then asked the patient to lie down on the examination table. He continued asking the patient questions while he performed the rest of the examination, which included taking the patient’s pulse, massaging the foot, and testing whether the patient could feel sensation in different areas of her foot.

Towards the conclusion of the examination, panelists as well as the audience were invited to ask questions, and an audience member wondered whether the presence of hair on the leg had clinical significance. Dr. Jaff noted that the women did not have hair, and her toenails were slightly dystropic but otherwise unremarkable. However, he said that he does not think those questions are worthwhile to ask, though he knows others in the field do pay attention to them. “People often don’t have hair on the lower part of their leg after wearing a sock for 15 or 20 years, so I don’t think that’s a helpful finding,” he said.

Dr. Jaff mentioned that he often sees “no c/c/e” (clubbing, cyanosis, edema) written in a chart as the only part of the physical examination of the legs. Although the edema is relevant, he pointed out that clubbing is rarely seen in the feet. “I never quite understood how that notation made it into the routine physical exam but pulses didn’t,” he said.

Another participant asked how Dr. Jaff distinguishes between peripheral neuropathy and rest pain in cases such as this one, in which the patient has both, and Dr. Jaff returned to the patient and continued the examination. As the examination was completed, Dr. Jaff thanked the patient for taking the time to contribute to physician education. The patient will be returning to further participate in a live case presentation on Tuesday.

—Lauren LeBano