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A Critical Review

Steven R. McGee, MD; Edward J. Boyko, MD, MPH

Arch Intern Med. 1998;158:1357-1364.

Objective  To determine the clinical utility of physical examination in patients with suspected chronic ischemia of the lower extremities.

Data Sources  MEDLINE search (January 1966 to January 1997), personal files, and bibliographies of textbooks on physical diagnosis, surgery, and vascular surgery.

Study Selection  Both authors independently graded the studies as level 1, 2, or 3, according to predetermined criteria. Criteria deemed essential for analysis of sensitivity, specificity, and likelihood ratios were (1) clear definition of study population, (2) clear definition of physical examination maneuver, and (3) use of an acceptable criterion standard test for comparison.

Results  The following positive findings help clinicians diagnose the presence of peripheral arterial disease: abnormal pedal pulses, a unilaterally cool extremity, a prolonged venous filling time, and a femoral bruit. Other physical signs help determine the extent and distribution of vascular disease, including an abnormal femoral pulse, lower-extremity bruits, warm knees, and the Buerger test. The capillary refill test and the findings of foot discoloration, atrophic skin, and hairless extremities are unhelpful in diagnostic decisions. Mathematical formulas, derived from 2 studies using multivariate analysis, allow clinicians to estimate the probability of peripheral arterial disease in their patients.

Conclusion  Certain aspects of the physical examination help clinicians make accurate judgments about the presence of peripheral arterial disease and its distribution.

From the Department of Medicine, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle.

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