Peripheral arterial insufficiency may involve both the upper and lower extremities. It may be due to obstruction, traumatic occlusion, arthrosclerosis, diabetes, Buerger’s disease, or Raynaud’s phenomenon. The patients who develop arterial insufficiency generally demonstrate one of three clinical patterns: (a) cold, cyanosed, livid and/or painful digits (Raynaud’s phenomenon); (b) digital ischemia; or (c) crampy pain on exercise (claudication). There is usually prolonged venous filling time following elevation of the extremity. The impaired flow or arterial insufficiency may be adequate to serve the metabolic activities of the muscles at rest but does not maintain the circulation necessary to the increased metabolic rates of exercise. Therefore, exercise testing, such as flexing and extending the arms and legs or walking, may reproduce the patient’s symptoms. Diagnosis is based on the combination of physical examination and vascular diagnostic testing, such as angiography, plethysmography, thermography, and vascular ultrasound.

Deep vein thrombosis (DVT) is a cordlike clot formation that usually arises in the deep veins of the calf muscles. This venous occlusion results in edema and dependent cyanosis. The cause may be iatrogenic or result from a mechanical trauma that injured the endothelium of the veins, hypercoagulability associated with malignant tumor or oral contraceptives, or stasis that occurs with prolonged bed rest. If left untreated, approximately 20% of thrombi may extend into the proximal venous system and pose a serious and even life-threatening risk of a pulmonary embolism: 90% of pulmonary emboli originate in the deep venous system of the legs.

Somatosensory amplification is usually a misrepresentation of the patient’s symptoms. It is seen in patients with hypochodriasis, patients with extreme anxiety disorder, or feigned for secondary gain. This is a very difficult assessment. Although this condition is most common in the setting of workers compensation and personal injury cases, the secondary gain may not be financial alone. It may occur if individuals desire a less strenuous job at work. They may gain control over fellow workers or family members. The injured party may allow others to do work that the patient would normally do.

The possibility of symptom magnification should be raised when major discrepancies or inconsistencies appear in the patient’s condition. These inconsistencies are most noted in history and physical examination. Some examples of these inconsistencies: (a) dramatized complaints that are vague or global, (b) overemphasized gait or postural abnormalities, (c) resistance to evaluation or rehabilitation, and (d) lack of motivation to develop new skills or lack of treatment compliance.

Once the information has been collected, a determination of symptom magnification may be made. This is difficult because very few symptom magnification cases are totally without pain or fear of being placed in a job perceived as potentially harmful. Second opinions are quite useful if you suspect symptom magnification. Concurrence by more that one physician is prudent in these cases.