Question

What I need is for you diagnose, Tell me why you chose that diagnosis. Signs, Symptoms, Age, lifestyle, any other factors to lead you to your conclusion. Give some diagnostic tests to confirm your Dx. Then a treatment plan.

Patient presents with a sore on his right big toe. Patient states sore has been there for 10 days and is not getting better if anything he thinks it is looking worse and fears infection. Patient also states his leg has been feeling strange for some time now, but he never paid much attention to it, also when he walks especially going upstairs his leg really hurts, he has to stop and take a break from walking. Patient is a 62 year old male who is overweight, admits to having a poor diet, and smoking. Patient also travels for work and spends a lot of time flying.

Answer 1

This is A Case of Peripheral Vascular Disease. I choose this Diagnosis because the patient is overweight, poor Diet and chronic Smoker. These risk factor leads to development of atherosclerosis, fatty deposits (plaques) build up on your artery walls and reduce blood flow leading to  Critical limb ischemia which begins as open sores that don't heal, an injury, or an infection of your feet or legs. Critical limb ischemia occurs when such injuries or infections progress and cause tissue death or gangrene formation. Also Maybe the Patient has Developed a Variant of Peripheral Vascular Disease that is Buerger's Disease that is specifically seen in Individuals who are Chronic Smokers.

Signs & Symptom of Peripheral Vascular Disease-

• ​Painful cramping in one or both thighs or calf muscles after certain activities, such as walking or climbing stairs (claudication)
• Leg numbness or weakness
• Coldness in your lower leg or foot, especially when compared with the other side
• Sores on your toes, feet or legs that won't heal
• A change in the color of your legs
• Slower growth of your toenails
• Shiny skin on your legs
• No pulse or a weak pulse in your legs or feet

It affects mostly Those people with Age > 50 years as the patient is 62 years old so, it is a Risk Factor.

Risk factors

Factors that increase your risk of developing peripheral artery disease include:

• Smoking
• Diabetes
• Obesity (a body mass index over 30)
• High blood pressure
• High cholesterol
• Increasing age, especially after reaching 50 years of age
• A family history of peripheral artery disease, heart disease or stroke
• High levels of homocysteine, a protein component that helps build and maintain tissue

Diagnotic Tests-

• Physical exam. Your doctor may find signs of PAD during a physical examination, such as a weak or absent pulse below a narrowed area of your artery, whooshing sounds (bruits) over your arteries that can be heard with a stethoscope, evidence of poor wound healing in the area where your blood flow is restricted, and decreased blood pressure in your affected limb.

• Ankle-brachial index (ABI). This is a common test used to diagnose PAD. It compares the blood pressure in your ankle with the blood pressure in your arm

  To get a blood pressure reading, your doctor uses a regular blood pressure cuff and a special ultrasound device to evaluate blood pressure and flow.

• Ultrasound. Special ultrasound imaging techniques, such as Doppler ultrasound, can help your doctor evaluate blood flow through your blood vessels and identify blocked or narrowed arteries.

• Angiography. Using a dye (contrast material) injected into your blood vessels, this test allows doctor to view blood flow through your arteries as it happens. Your doctor is able to trace the flow of the contrast material using imaging techniques, such as X-ray imaging or procedures called magnetic resonance angiography (MRA) or computerized tomography angiography (CTA).

• Blood tests. A sample of your blood can be used to measure your cholesterol and triglycerides and to check for diabetes

Treatment-

​​​​​​There are two types of treatment therapies Medical and Surgical.

Medications

• Cholesterol-lowering medications. You may take a cholesterol-lowering drug called a statin to reduce your risk of heart attack and stroke.

  The goal for people who have peripheral artery disease is to reduce low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, to less than 100 milligrams per deciliter (mg/dL).

• High blood pressure medications. If you also have high blood pressure, your doctor may prescribe medications to lower it. Achieving 130/80 mm Hg is also the goal for healthy adults age 65 and older and healthy adults younger than age 65 with a 10 percent or higher risk of developing cardiovascular disease in the next 10 years.

• Medication to control blood sugar. If you also have diabetes, it becomes even more important to control your blood sugar (glucose) levels.

• Medications to prevent blood clots. Because peripheral artery disease is related to reduced blood flow to your limbs, it's important to improve that flow.

  Your doctor may prescribe daily aspirin therapy or another medication, such as clopidogrel (Plavix).

• Symptom-relief medications. The drug cilostazol increases blood flow to the limbs both by keeping the blood thin and by widening the blood vessels. It specifically helps treat symptoms of claudication, such as leg pain, for people who have peripheral artery disease. Common side effects of this medication include headache and diarrhea.

  An alternative to cilostazol is pentoxifylline. Side effects are rare with this medication, but it’s generally less effective than cilostazol.

Angioplasty and surgery

• Angioplasty. In this procedure, a small hollow tube (catheter) is threaded through a blood vessel to the affected artery. There, a small balloon on the tip of the catheter is inflated to reopen the artery and flatten the blockage into the artery wall, while at the same time stretching the artery open to increase blood flow.

  Your doctor may also insert a mesh framework called a stent in the artery to help keep it open. This is the same procedure doctors use to open heart arteries.

• Bypass surgery. Your doctor may create a graft bypass using a vessel from another part of your body or a blood vessel made of synthetic (man-made) fabric. This technique allows blood to flow around — or bypass — the blocked or narrowed artery.
• Thrombolytic therapy. If you have a blood clot blocking an artery, your doctor may inject a clot-dissolving drug into your artery at the point of the clot to break it up.