Case
- 80 y.o., pensioner
- Pain in R leg
- Onset 4 months ago |
- Pain comes on about half way through his walk to shop (400m), eases off if he sits for a while, then able to resume
- Same thing happens on way back
- 'Cramp-like' sensation
- ABPI (diagnosis PAD): 0.8 (results last week) |
AF: walking
RF: sitting
AA: walking to shop |
Extras
- Hypertension since 55 y.o.
- Hypercholesterolemia diagnosed 10 yrs ago
- Coronary angioplasty 2 yrs ago (following episodes of angina)
- Aspirin (300mgs/day; NSAID)
- Atorvastatin (prevents cardiovascular disease in high risk pts)
- Lisinopril (treats high BP)
- Smoked 20/day since teens
- Drinks pint of ale most nights
- Lives alone (wife died 2 yrs ago)
- 2 children who he doesn't see often
- Doesn't enjoy eating much anymore now he is on his own |
Physical Examination Findingscal
BP:R+L 160/100 |
General observations
- Looks underweight
- Feet look pale & feel cool to the touch
- No swelling in legs |
Skin
- Nicotine staining on fingers from smoking |
Chest, cardiovascular & respiratory
- Bruit (partially occluded artery) one the R femoral artery |
Peripheral inspection & pulses
- Diminished dorsals pedis * posterior tibia's pulses in the R leg |
Clinical tests
- Good ROM at the hips & knees
- Full Lx ROM
- Feels muscle stretch behind knees on full flexion |
Discussion
Working diagnosis
- Peripheral Arterial Disease (PAD) |
- Non-MSK
- Vascular w/ key Hx findings being cramping pain
- AF: set distance
- RF: sitting
- ABPI: 0.8, which supports working Dx
- Several risk factors for PAD including existing CV disease & being a heavy smoker & drinker
- Feet look pale & are cool: suggests that PAD is more advanced than the ABPI suggests
- Diminished pulses in LL w/ bruit over R femoral artery |
Yellow flags
- High blood pressure
- Underweight
- Nutritional status
- Limited social interactions / social isolation
- Possible depression |
Learning Outcomes
Understand Peripheral Arterial Disease (PAD)
- Describes stenosis/occlusion of peripheral arteries, affecting blood supply to extremities, usually LL
- Commonly caused by atherosclerosis
⏺ Acute limb ischemia:
- Sx & Ssx develop over <2 weeks
- Sudden onset leg pain
- Sudden deterioration of claudication, associated loss of pulses &/or pallor
- Coldness/cyanosis of limb
- Loss of motor/sensory functions
⏺ Chronic limb ischemia:
- Progressive development of cramp-like pain in calf, thigh or buttock (atypical terms: tired, giving way, sore, hurts - rather than describing cramp)
- LL pain on walking/exercise, relieved by rest
- Unexplained leg/foot pain
- Non-healing wounds to LL
- ABPI 0.0-0.4
⏺ Risk factors:
- Smoking
- Drinking
- Hx of CV disease
- Diabetes mellitus |
Differentiate vascular from neurogenic claudication
⏺ Vascular claudication:
- Caused by reduced blood flow to LL
→ Sx & Ssx:
- pain in calves, thighs, or buttocks
- Pain during walking/exercise
- Relieved by rest
- 'Cramping' or 'burning' sensation
- Legs may feel cold, numb, or weak
- Visible signs of poor circulation: skin may appear paler blue, slow wound healing
- Absent/poor LL pulses
⏺ Neurogenic claudication:
- Caused by nerve compression/damage in lower back
→ Sx & Ssx:
- Pain inlayer back, buttock, legs (above knees usually)
- Aggravated by standing & walking
- Relieved by sitting or leaning forward
- 'Deep ache' or 'numbness' sensation
- Associated tingling, weakness, shooting pains in legs
⏺ Investigations:
- Ankle-brachial index test (ABPI): evaluate blood flow to the legs
- Electromyography (EMG) or nerve conduction studies: evaluate nerve function
- MRI or CT: evaluate the spine & surrounding structures |
Differentiate PAD from other vascular disorders
⏺ PAD:
- Pain in the calves, thighs, buttocks
- Pain during walking/exercise
- Improves w/ rest
- Other Sx: numbness, weakness, coldness
- Skin may appear pale, shiny, discoloured, cool to touch
- Hair loss/slow growth
- Slow wound healing
- Ulcers/sores
⏺ DVT:
- Pain unilaterally
- Other Sx: swelling, redness, warm area
- Aggravated by standing/walking
- May not improve w/ rest
- Skin may appear discoloured, veins visible on skin surface
- Risk: Hx immobility, surgery, family Hx of clots
⏺ Chronic Venous Insufficiency (CVI):
- Pain, fatigue, heaviness in legs
- Swelling, possible varicose veins
- Skin appeared thickened, discoloured
- Pain worse w/ prolonged standing/sitting, may improve w/ leg elevation
- Risk: pregnancy, family Hx of varicose veins |
How to interpret ABPI?
- <0.5: suggests severe arterial disease
- 0.6 - 0/7: suggest presence of arterial disease or mixed arterial/venous disease
- 0.8 - 1.3: suggest no evidence of significant arterial disease
- >1.3: may suggest presence of arterial calcification (such as pts w/ diabetes, RA, systemic vasculitis, atherosclerotic disease, & advanced chronic renal failure) |
Differentiate typical from atypical cramp
⏺ Typical cramp:
- Often occur in legs (esp. calves), feet, hands
- AF: during/after exercise & may be related to muscle fatigue or dehydration
- RF: stretching or massage
- Last up to 10 min
- Doesn't usually occur frequently or interfere significantly w/ ADL
⏺ Atypical cramp:
- In any muscle, including those not typically affected by cramps
- Occur without obvious trigger / after minimal activity
- Accompanied by other Sx: weakness, stiffness, twitching
- May last longer, & feel more severe
- May occur frequently or interfere w/ ADL |
AECC clinic risk management for hypertension
- <140/90: no action required
- 140/90 - <160/100: BP to be measured at next follow-up appt; Letter to GP within 1 week if still >140/90
- 160/100 - <180/110: Tell pt to see GP within 1 week; Tutor send letter to GP within 48hrs; BP to be measured at 1st follow-up appt
- >180 systolic OR >110 diastolic: Floor tutor check BP manually; tutor tell pt to see GP the sea day; Tutor to follow up GP letter same day |
Screening questions fro depression
1. During the last month have you often been feeling down, depressed or hopeless?
2. During the last month have you often been bothered by having little interest or pleasure in doing things?
IF ANSWER 'YES' TO ONE/BOTH, FOLLOW UP WITH:
- During the last month, have you often been bothered by:
3. Feeling bad about yourself or that you're a failure or have let yourself or your family down?
4. Poor concentration?
5. Tiredness/ low energy levels?
6. Changes in appetite (reduced or increased)?
7. Changes in your sleep pattern (sleeping too much, problems getting to sleep, waking in the night or waking early)?
8. Being so slowed down, or so restless/fidgety, that other people have noticed?
9. Thoughts of death? |
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