Peripheral Arterial Disease
Patient presentation:
K.B., a 68 year old female presents to her primary care doctor with complaints of frequent severe leg cramping, generalized pain in the hips and legs, difficulty being on her feet for longer than a half hour, and she had recently noticed one of her toenails was black. The patient stated that usually her pain is relived with rest until now. She reports these vague symptoms started getting increasingly worse, approximately 2 months ago, but it was not until the black toenail that she sought medical attention. Her past medical history is remarkable for diverticulitis, HTN, type 2 Diabetes, and anxiety disorder. She also has a 65 pack-year smoking history.
Differential Diagnoses:
PAD
Diabetic sensory neuropathy
Reflex sympathetic dystrophy
Vasculitis
Spinal stenosis
Arthritis
Diagnosis:
The patient’s ankle brachial index is measured to be 0.60 with a bilateral lower extremity duplex study. The patient is also sent for an MRI of her lower extremities. A full physical exam is done as well. It is found on exam that the patient has no palpable pedal pulses, they are found to be very faint with the Doppler. Her toes are shiny and hairless, with capillary refill greater than 3 seconds. The diagnosis of PAD is given to the patient, in the presence of these findings.
Treatment and outcome:
The patient is sent to surgery for a bilateral femoral above-knee popliteal bypass. The surgery was uncomplicated. The patient was started on morphine and Percocet® for pain, baby aspirin daily and Plavix®, for anti-platelet treatment, then was sent to the Surgical Intermediate Unit for the post-op period. The patient developed a right surgical wound infection and the grafts ultimately failed. The surgical wounds eventually dehisced after the patient developed significant lower extremity edema. The patient subsequently developed sepsis and had a very poor prognosis. Unfortunately the patient did not survive.
Case created by Kate Bradbury, 2010.