Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the vascular system.

• The extremities are normal in color, size, and temperature. All pulses in the upper and lower extremities are grade 2 and are equal. No bruits are present. No clubbing, cyanosis, or edema is present.

• There are yellow, waxy, sharply demarcated lesions on both anterior shins. Both legs appear slightly cool, the left greater than the right. There is a punched-out ulceration on the lateral aspect of the left ankle. The left big toe is blackened, with a sharp demarcation. The femoral pulses are grade 2 bilaterally. No distal pulses are felt. There is 1+ pretibial edema present bilaterally. No clubbing or cyanosis is present.

• The right lower extremity is 3 cm larger than the left, measured 4 cm below the inferior aspect of the patella. The right calf is tender, warm, and erythematous. A cord is palpated in the right groin. Both lower extremities are edematous

Table 15-4 Differential Diagnosis of the Main Vascular Diseases Causing Gangrene

Feature Diabetes Atherosclerosis Thromboangiitis Obliterans Raynaud's Disease Arterial Embolism and hyperpigmented. There is 3+ pretibial edema on the right and 2+ pretibial edema on the left. A small ulceration is present above the left medial malleolus. The arterial pulses are grade 2 at the femoral arteries and grade 1 at the popliteal arteries. No pulses are palpated distal to the popliteal arteries. No clubbing or cyanosis is present.

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