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5002 Case 12 Cheat Sheet by

Peripheral Arterial Disease (PAD) - typical cramping pain aggravated by a set distance & relieved by sitting

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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