Recommendations for History and Physical Examination
COR	LOE	Recommendations
I	B-NR	Patients at increased risk of PAD (Table 4) should undergo a comprehensive medical history and a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and nonhealing wounds.52–57
See Online Data Supplement 1.		The symptoms and signs of PAD are variable. Patients with PAD may experience the classic symptom of claudication or may present with advanced disease, including CLI. Studies have demonstrated that the majority of patients with confirmed PAD do not have typical claudication but have other non–joint-related limb symptoms or are asymptomatic.53,55 Atypical lower extremity symptoms related to PAD may include pain or discomfort that begins at rest but worsens with exertion, pain or discomfort that does not stop an individual from walking, and pain or discomfort that begins with exertion but is not alleviated within 10 minutes of rest.54 Patients with PAD who do not have typical claudication but have other leg symptoms, or who are asymptomatic, have been shown to have functional impairment comparable to patients with claudication.54 Thus, all patients at increased risk of PAD should be asked not only about claudication but also about other exertional non–joint-related limb symptoms and perceived walking impairment.
I	B-NR	Patients at increased risk of PAD (Table 4) should undergo vascular examination, including palpation of lower extremity pulses (ie, femoral, popliteal, dorsalis pedis, and posterior tibial), auscultation for femoral bruits, and inspection of the legs and feet.56,58,59
See Online Data Supplements.		A thorough lower extremity vascular examination and careful inspection of the legs and feet are important components of the clinical assessment for PAD. To perform a thorough examination, legs and feet are examined with lower garments (pants/skirt, shoes, and socks) removed. Examination findings suggestive of PAD are shown in Table 5. Lower extremity pulses should be assessed and rated as follows: 0, absent; 1, diminished; 2, normal; or 3, bounding. Reproducibility of pulse assessment is better for detection of normal versus absent pulse than for normal versus diminished pulse.56 Absence of the dorsalis pedis pulse is less accurate for diagnosis of PAD than is absence of the posterior tibial pulse because the dorsalis pedis pulse can be absent on examination in a significant percentage of healthy patients.56,58 The presence of multiple abnormal physical findings (ie, multiple pulse abnormalities, bruits) increases the likelihood of confirmed PAD.56,58,59 Abnormal physical findings, such as a pulse abnormality, require confirmation with the ankle-brachial index (ABI) to establish the diagnosis of PAD. Similarly, an entirely normal pulse examination and absence of bruits decreases the likelihood of confirmed PAD.56,58 The presence of nonhealing lower extremity wounds may be a sign of CLI. Findings of cool or discolored skin and delayed capillary refill are not reliable for PAD diagnosis.56 To confirm the diagnosis of PAD, abnormal physical examination findings must be confirmed with diagnostic testing (Section 3), generally with the ABI as the initial test.
I	B-NR	Patients with PAD should undergo noninvasive blood pressure measurement in both arms at least once during the initial assessment.60–62
See Online Data Supplement 1.		An inter-arm blood pressure difference of >15 to 20 mm Hg is abnormal and suggestive of subclavian (or innominate) artery stenosis. Patients with PAD are at increased risk of subclavian artery stenosis.60–62 Measuring blood pressure in both arms identifies the arm with the highest systolic pressure, a requirement for accurate measurement of the ABI.27 Identification of unequal blood pressures in the arms also allows for more accurate measurement of blood pressure in the treatment of hypertension (ie, blood pressure is taken at the arm with higher measurements). Although a difference in arm systolic pressures of >15 to 20 mm Hg suggests subclavian (or innominate) artery stenosis, in the absence of symptoms (eg, arm claudication or symptoms of vertebral artery steal), no further imaging or intervention is warranted.