The physical examination should not be limited to the examination of the arteries of the extremities, but should also include an examination of the systemic cardiovascular system. In addition to examining other clinical manifestations of atherosclerosis, there is a general systemic examination, including associated damage due to concomitant systemic non-vascular disease, as these manifestations will be important in the development of an overall treatment plan. Perfusion of the arteries of the extremities The pulse must be palpated and auscultated for vascular murmurs, as well as examined for trophic changes and other dermatologic changes of peripheral arterial disease, with additional clinical functional examinations required for specific problems. Physical examination findings are usually sufficient to make a significant determination of the degree of arterial hypoperfusion and the site of underlying arterial vascular changes. Pulses The standard pulse palpation procedure involves a serial bilateral comparison of the radial ulnar, femoral, N, and posterior tibial arteries behind the medial ankle, as well as the dorsalis pedis artery pulsations. If unclear or abnormal findings are noted, or if there is doubt about the axillary, brachial, and peroneal artery regions, palpation of the distal geniculate branches of the axillary, brachial, and peroneal arteries is performed. A normal pulse does not exclude peripheral arterial disease: the pulse may remain normal when the geniculate branches (internal iliac artery, deep femoral artery) are involved alone, and may be clearly palpable even when the major arteries (mainly iliac, occasionally also in the groin) are narrowed and already clinically symptomatic. In typical cases of claudication, a history coupled with a normal pulse and a stenotic murmur can provide important clues. In suspected cases, conclusive evidence must be obtained by exercise testing or imaging. Auscultation Arterial murmurs are suggestive of arterial stenosis and should be auscultated in the aorta, subclavian, cervical, ventral, iliac, common femoral, superficial femoral and N arteries. A vascular murmur does not imply arterial stenosis, as arterial murmurs can also occur from obstruction of the geniculate vessels and are conducted from the heart in patients with high circulating volumes (e.g., hyperthyroidism), anemia, and arteriovenous fistulas. Vascular murmurs in young people may also be physiologic in nature. The sensitivity of auscultation to detect arterial stenosis reaches its limit when the stenosis is mild (less than 50% diameter reduction) or too severe (>90% diameter reduction), at which point the murmur is often not heard. Dermatologic changes and trophic injury Special attention should be paid to venous filling, skin color and temperature, sweat hair loss in the limb area, hyperkeratosis of the plantar skin, toenail mycosis, decubitus ulcers, dermatologic defects, gangrene, and local inflammatory conditions. The examination should not be limited to easily observable areas of the limb, but must also include the interphalangeal area. Claudication/Treadmill Test When the exact distance walked is unclear, or when concomitant disease is suspected to limit movement, a claudication test should be performed to provide an objective understanding of the limitation in walking distance. The standard procedure for this test should be to set a speed of 3.0 km/h or 3.2 km/h (equivalent to 2 mph) on a bicycle with a 12% gradient. If there is no available treadmill or the patient is not able to perform the treadmill test, the patient may be asked to walk on a flat surface at a speed of two steps per second (equivalent to 5 km/h). The initial and absolute claudication distance, the site of pain, the reason for stopping walking, and any other symptoms present during the walking test are recorded. Peripheral arterial disease does not always cause pain during walking and occasionally only complains of equivalent fatigue of the limb (especially in patients with the thoracic girdle or abdominal aorto-iliac type). Ratschow’s test/clenched fist provocation test When diagnosing PAD, pulse, ankle and/or hand/wrist artery blood pressure may appear normal or only slightly variable when distal peripheral vascular injury (calf type or forearm type) is present, even in some cases of severe circulatory disturbances, which can be easily misleading. Therefore, a Ratschow’s test or a clenched fist provocation test must be performed when the corresponding clinically suspicious case is encountered. Other cardiovascular systems Peripheral arterial disease is usually a clinical manifestation of obstructive atherosclerosis and is indicative of atherosclerotic changes in other vascular systems. Therefore, in a patient with an arterial circulation disorder, the history and physical examination should also be directed to coronary artery disease and stenotic lesions in the extracranial arteries supplying the brain, in addition to other important clinical manifestations of atherosclerosis, such as visceral artery stenosis and aneurysms.