As noted, PAD refers to stenotic, occlusive, and aneurysmal disease of the abdominal aorta, its mesenteric and renal branches, and the arteries of the lower extremities, exclusive of the coronary arteries. Pain in the extremities can also arise from the skin, musculoskeletal system, or nervous system. It may also be referred, like the pain of myocardial infarction that radiates to the left arm.

■ Ask about abdominal, flank, or back pain, especially in older smokers. Is there unusual constipation or distention? Inquire about for urinary retention, difficulty voiding, or renal colic.

■ If there is persisting abdominal pain, ask about any related "food fear," weight loss, or dark stool.

■ Ask about any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes, called intermittent claudication.

■ Ask also about coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces.

Because most patients with PAD report minimal symptoms, enquire about two common types of atypical leg pain from PAD that occur prior to critical limb ischemia: leg pain on exertion and rest (exertional pain that can begin at rest), and leg pain/carry on (exertional pain that does not stop the patient from walking). 

Ask specifically about the PAD warning signs that follow, particularly in patients aged ≥50 years and those with PAD risk factors, especially smoking, but also diabetes, hypertension, elevated cholesterol, African American ethnicity, or coronary artery disease. When the symptoms or risk factors described in the box below are present, pursue careful examination and testing with the ankle–brachial index (ABI)

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