Question

A 68-year-old retired male 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 relieved with rest. Two years ago, the client could walk two city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. He has smoked two to three packs of cigarettes per day 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 x 4) 3 years ago, and an open reduction internal fixation (ORIF) of a right femoral fracture 20 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 packs per day.

The client 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.

General assessment data: Weight 261 lb; Height 5 ft 10 in; Blood pressure 163/91 mmHg; Pulse 82 beats per minute; Respirations 16 breaths per minute; Temperature 98.4^o F.

Laboratory Testing: Cholesterol 239 mg/dL; Triglycerides 150 mg/dL; HDL 28 mg/dL; LDL 181 mg/dL.

Current Medications: Ramipril 10 mg/day; Metoprolol 25 mg bid; Aspirin 81 mg/day; Simvastatin 20 mg/day.

1. What are the abnormals and their clinical significance?
2. Prioritize the top 3 abnormals.

3. List the 5 most important interventions for the top priority (from question #2) and provide the rationale for each intervention.
4. What are the expected outcomes of each intervention (from question #3)?
5. What are 3 potential complications that could happen with this client?
6. What are potential causes of the client’s symptoms?

7. List at least 7 clinical manifestations would you expect to find with PAD.

The primary care provider orders ankle-brachial index (ABI) test to determine the presence of arterial blood flow obstruction. The ABI results showed 0.43 right leg and 0.59 left leg. These results were discussed with the client and the provider decides to wait 2 months to see whether his symptoms improve with medication changes and risk factor modification before deciding about surgical interventions. He receives a prescription for clopidogrel 75 mg/day and is told to discontinue the daily aspirin. In addition, he receives a consultation for physical therapy.

8. What do these ABI results indicate?
9. (Opinion Question) You counsel the client on risk factor modification and other measures to improve tissue perfusion and to prevent skin damage. What should be addressed and provide the rationale?

68-year-old retired male 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 relieved with rest. Two years ago, the client could walk two city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. He has smoked two to three packs of cigarettes per day 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 x 4) 3 years ago, and an open reduction internal fixation (ORIF) of a right femoral fracture 20 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 packs per day.

The client 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.

General assessment data: Weight 261 lb; Height 5 ft 10 in; Blood pressure 163/91 mmHg; Pulse 82 beats per minute; Respirations 16 breaths per minute; Temperature 98.4o F.

Laboratory Testing: Cholesterol 239 mg/dL; Triglycerides 150 mg/dL; HDL 28 mg/dL; LDL 181 mg/dL.

Current Medications: Ramipril 10 mg/day; Metoprolol 25 mg bid; Aspirin 81 mg/day; Simvastatin 20 mg/day.

What are the abnormals and their clinical significance?

Prioritize the top 3 abnormals.

List the 5 most important interventions for the top priority (from question #2) and provide the rationale for each intervention.

What are the expected outcomes of each intervention (from question #3)?

What are 3 potential complications that could happen with this client?

What are potential causes of the client’s symptoms?

List at least 7 clinical manifestations would you expect to find with PAD.

The primary care provider orders ankle-brachial index (ABI) test to determine the presence of arterial blood flow obstruction. The ABI results showed 0.43 right leg and 0.59 left leg. These results were discussed with the client and the provider decides to wait 2 months to see whether his symptoms improve with medication changes and risk factor modification before deciding about surgical interventions. He receives a prescription for clopidogrel 75 mg/day and is told to discontinue the daily aspirin. In addition, he receives a consultation for physical therapy.

What do these ABI results indicate?

(Opinion Question) You counsel the client on risk factor modification and other measures to improve tissue perfusion and to prevent skin damage. What should be addressed and provide the rationale?

Answer 1

Here ,68yrs old man with known case of

• Coronary artery disease
• Peripheral artery disease
• Osteoarthritis
• Hypertension

With the present complaints of...

• Right calf pain worsen from the last 4months.pain precipitated by exercise and improve by rest
• Hip pain that get worse with exercise also affected in resting position.
• Bp is 163/91mmhg
• Weight is 261ibs
• High cholesterol levels.

These are the signs and symptoms of PAD.Here client is known case of PAD.

Peripheral artery disease is the condition sings of fatty deposits and calcium building up in the arteries .

**Main 3 complaints are here is ..

Right calf pain,hip pain high cholesterol, high blood pressure.

I**nterventions with rational.

1. Adivise to do regular physical activities it can be under supervision also .strats off slowly from the simple.it will help to decreased symptoms slowly in one to two months.
2. Advise to change dietery plan with low in saturated fats,trans fat, and cholesterol .include more fruits and vegetables. It will help to lower the Cholesterol levels.
3. Advise to stop smoking. It will help to slow the progression of PAD also other heart problems.
4. Regular check up for blood pressure .it will help to identify and treat high pressure.
5. Advise to take medication as per doctors order .it will help yo relieve symptoms

*Expected outcome*

Peoples with PAD may not have enough blood flow to their leg muscles because of claudiness.it results pain during exercise. But increasing amount of walk can train the muscles to work with less oxygen. Addition to this other life changes ,medication ,cessation of smoke will helps too .

**potential complications***

• Loss of limb (amputation)
• Poor wound healing.
• Heart attack.
• Stroke.
• Restricted mobility due to pain .

**potential causes of PAD**

• Smoking.
• Obesity.
• high blood pressure.
• High cholesterol
• Increasing age
• Known case of heart disease .

Expected clinical manifestation of PAD

1. Pain in cslfs of legs .
2. Pain in thighs
3. Numbness
4. Weakness of legs
5. Sores on foot
6. Change colour of legs.
7. Sshiny skin.
8. Slower growth of toenails.
9. Week pulse or no pulse.

ABI for PAD

Here his ABI is showing moderate pad

Ratio 1to 1.4 is normal.ABI ratio .4 yo .7shows moderate PAD.

*risk factor modifications by*

Dietery adjustment, lfr style changes,daily exercise, cessation of smoking, use shoes while walking to prevent ulcers. Regular check up , all these will help to prevent or control PAD .And also the further complications.