Peripheral Artery Disease S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately 2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise and is relieved with rest. Two years ago, S.P. could walk two city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. S.P. has smoked two to three packs of cigarettes per day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN), peripheral artery disease (PAD), and osteoarthritis. Surgical history includes quadruple coronary artery bypass graft (CABG×4) 3 years ago. He has had no further symptoms of cardiopulmonary disease since that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed, continues to eat anything he wants, and continues to smoke two to three PPD. Other surgical history includes open reduction internal fixation of a right femoral fracture 20 years ago .S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care provider. As you take his vital signs, he tells you that in addition to the calf pain, he is experiencing right hip pain that gets worse with exercise, the pain doesn't go away promptly with rest, some days are worse than others, and his condition is not affected by a resting position. Chart View General Assessment Weight 261lb Height 5ft, 10 in Blood pressure (BP) 163/91mm Hg Pulse 82 beats/min Respiratory rate 16 beats/min Temperature 98.4° F (36.9° C) Laboratory Testing (Fasting) Cholesterol 239mg/dL Triglycerides 150mg/dL HDL 28mg/dL LDL 181mg/dL Current Medications Ramipril (Altace) 10mg/day Metoprolol (Lopressor) 25mg twice a day Aspirin 81mg/day Simvastatin (Zocor) 20mg/day 1. What are the likely sources of his calf pain and his hip pain? 2. S.P. has several risk factors for PAD. From his history, list two risk factors, and explain the reason they are risk factors 3. You decide to look at S.P.'s lower extremities. What signs do you expect to find with PAD? Select all that apply. a. Cool or cold extremity b. Thin, shiny, and taut skin c. Brown discoloration of the skin d. Decreased or absent pedal pulses e. Ankle edema f. Thick, brittle nails 4. You ask further questions about the clinical manifestations of PAD. Which of these would you expect S.P. to have, given the diagnosis of PAD? Select all that apply. a. Dependent rubor b. Paresthesia c. Constant, dull ache in his calf or thigh d. Rest pain at night e. Pruritus of the lower legs f. Elevation pallor 5. What is the purpose of the daily aspirin listed in S.P.'s current medication? CASE STUDY PROGRESS S.P.'s primary care provider has seen him and wants you to schedule him for an ankle-brachial index (ABI)test to determine the presence of arterial blood flow obstruction. You confirm the time and date of the procedure and then call S.P. at home. 6. What will you tell S.P. to do to prepare for the tests? CASE STUDY PROGRESS S.P.'s ABI results showed 0.43 right (R) leg and 0.59 left (L) leg. His primary care provider discusses these results with him and decides to wait 2 months to see whether his symptoms improve with medication changes and risk factor modification before deciding about surgical intervention. S.P. receives a prescription for clopidogrel (Plavix) 75mg daily and is told to discontinue the daily aspirin. In addition, S.P. receives a consultation for physical therapy. 7. What do these ABI results indicate 8. You counsel S.P. on risk factor modification. What would you address, and why 9. How will the physical therapy help? 10. In addition to risk factor modification, what other measures to improve tissue perfusion or to prevent skin damage should you recommend to S.P 11. S.P. tells you his neighbor told him to keep his legs elevated higher than his heart and asks for compression stockings to keep swelling down in his legs. How should you respond? 12. S.P. has been on aspirin therapy but now will be taking clopidogrel instead. What is the most important aspect of patient teaching that you will emphasize with this drug?
