Case study PVD students case studies for clinical PDF

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Case study PVD

Scenario 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 2 to 3 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 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 2 to 3 PPD. Other surgical history includes open reduction and 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 does not go away promptly with rest, some days are worse than others, and his condition is not affected by a resting position.

General Assessment Weight

261 lb (118.4 kg)

Height

5 ft, 10 in (178 cm)

BP

163/91

Pulse

82 beats/min

Respiratory rate

16 beats/min

Temperature

98.4°F (36.9 º C)

Laboratory Testing (Fasting) Cholesterol

239 mg/dL (6.2 mmol/L)

Triglycerides

150 mg/dL (1.69 mmol/L)

HDL

28 mg/dL (0.73 mmol/L)

LDL

181 mg/dL (4.69 mmol/L)

Current Medications Ramipril (Altace)

10 mg daily

Metoprolol (Lopressor)

25 mg twice a day

Aspirin

81 mg daily

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Atorvastatin (Lipitor)

20 mg daily

1. What are the likely sources of his calf pain and hip pain?  Patient had a femoral fracture 20 years ago and is now 68 years-old and also weighs 261 lbs which is a lot to have on an elderly body that still ambulates.

2. S.P. has several risk factors for PAD. From his history, list 2 risk factors, and explain the reason they are risk factors.

 

Smoking is a number one risk factors for PAD it can cause hypertension and increase heart rate by increasing the chances of arterial plaque buildup. We discussed Hypertension and Strokes with AVM in class which can contribute to PAD as well. Hypertension causes stress on blood vessels the excess force from that stress increases the chances of PAD.

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.Ankle edema b.Thick, brittle nails c.Cool or cold extremity d.Thin, shiny, and taut skin e.Brown discoloration of the skin f. Decreased or absent pedal pulses

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.Paresthesia b.Elevation pallor c.Dependent rubor d.Rest pain at night e.Pruritus of the lower legs f. Constant, dull ache in his calf or thigh

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5. What is the purpose of the daily aspirin listed in S.P.’s current medication?  To prevent him from having a thromboembolism by inhibiting platelet aggregation

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?  Procedure is short and painless no need to be NPO.  Wear clothes that are comfortable for obtaining vitals and lose fitting.  Stop smoking at least 30 mins to an hour prior to procedure because nicotine can alter results.

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 drug changes and risk factor modification before deciding about surgical intervention. S.P. receives a prescription for clopidogrel (Plavix) 75 mg 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?  The ABI is determined by dividing two ankle BP’s (the ankle and brachial). His results show that his right leg ABI is lower than the left leg which tells us that the right leg is being affected more than the left leg, these results show severe PAD.

8. You counsel S.P. on risk factor modification. What would you address, and why?

   

Take BP medication to ensure BP is controlled. Stop smoking immediately this will prevent progression of disease. Ensure you take medication every day, on time when scheduled Workout and stay active to increase blood flow to extremities

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9. You provide teaching on proper care of his feet and lower extremities, then use “teachback” to assess S.P.’s learning. Which statements by S.P. indicate a need for further instruction? Select all that apply. a.“I can go barefoot in the house, but not outside.” b.“I will wear shoes that are roomy and protective.” c.“I will avoid exposing my feet to extremes of heat and cold.” d.“I will soak my feet in water once a day to make sure they are clean.” e.“I will put lotion on my feet and lower legs, but not in between the toes.”

10. How will the physical therapy help?  As stated, before exercise, working out and physical therapy will all help with healing, blood flow and circulation to all extremities to the body. The more and more frequent the body exercises and gets use to the more successful blood flow and circulation are. 11. In addition to risk factor modification, what other measures to improve tissue perfusion or prevent skin damage should you recommend to S.P.? 

Heating pad and applied heat



Hydration

 

Always protect feet with socks or shoes never go barefoot Use minimal pressure when drying or using lotion

12. 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?  Glad you told me this information before trying it. 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.

13. 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? 

At risk for bleeding due to blood thinner

CASE STUDY OUTCOME

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S.P. asks for nicotine patches to assist with smoking cessation and makes an appointment for a physical therapy evaluation and a nutritional assessment. He assures you he does not want to lose his leg and will be more careful in the future.

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