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?
The patient had a femoral fracture 20 yrs ago, he wighs 261 lbs and weighs 261.
2. S.P. has several risk factors for PAD. From his history, list two risk factors, and explain the
reason they are risk factors
smoking, hypertension, age, obesity
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 : tingling of the peripheral nerves
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?
Hemorheologic and antiplatelet agents.
Pentoxifylline
Aspirin, clopidogrel
Patients should not take clopidogrel should not eat grapefruit or drink grapefruit juice because of risk
of kidney failure, gi bleeding, heart failure, or even death.
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?
Continue drug therapy, explain what the contraindications are…. Do not use grapefruit with
clopidogrel. Exercise, stop smoking, dash diet/Mediterranean diet.
9. How will the physical therapy help?
Physical therapy will help with circulation, to reduce blood clots
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?
keep feet dry, and protected, skin care. Stay hydrated to maintain good circulation and reduce skin
breakdown of feet. Use heating pads, or try to stay warm. Stay away from the cold because it
impedes circulation. Also do not use too much pressure when drying your feet.
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?
The treatments are different for what you have and the venous problems he is those compression
stockings could possibly impair circulation for you which is the opposite of what we want to do.
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?
Clopideogrel is used to reduce MI, stroke, and vascular death.
At risk for bleeding due to blood thinner. Do not use grapefruit or grapefruit juice because of risk of
kidney failure, gi bleeding, and heart failure.
Bleeding time is longer, so he needs to apply pressure longer.
Tell other health care providers that he is taking blood providers