DrVirgo
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A 63 year old man comes to the physician because of a 6 month history of severe pain in both legs whenever he walks more than a block. The pain consistently occurs after one block of walking and is relieved by rest. he has no nocturnal or rest pain. he has a history of hypertension, diabetes, and hypercholesterolemia. he is a heavy smoker. He takes amlodipine, ramipril, and atorvastatin. his blood pressure is 150/90 mmHg and pulse is 70/min. Examination shows some hair loss of the lower legs; he has brittle toenails bilaterally. The femoral and poplitial pulses are weak, but ptesent. The distal leg pulses are absent bilaterally. Which of the following is the most appropriate next step in management?
A. Angiogram to determine the extent of disease
B. Surgical revascularization
C. Aspirin and exercise program
D. Sympathectomy
E. Angioplasty
Please explain your answer and WHY you think it's right. Thanks.
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| Justice
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Yea, it's a tough Qn... I am trying to find the best answer but from options A or C... The extend (A) is already "kind of" known by palpation... So, C?
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| CocaCola
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???
A - to determine extent of disease...
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| DrVirgo
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I thought A too, but the right answer is C.
Now how are you going to tell this old man to go exercise when he can't even walk a block due to pain???!!!???
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| Justice
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DrVirgo wrote:I thought A too, but the right answer is C. Now how are you going to tell this old man to go exercise when he can't even walk a block due to pain???!!!???
Well, A is an invasive procedure, and cannot be easily approved without therapeutic interventions.
Exercise does not mean the man has to spend 8 hr/day on a treadmill, but rather means (hopefully) a gradual increase and possibly a tolerance improvement...
I personally hate this kind of qns...
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| DrVirgo
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This is the explanation according to Kaplan:
The workup for disabling intermittent claudication:
1. Starts with Doppler Studies looking for a pressure gradient.
2. If there isn't one, the disease is in the small vessels and you can't do surgery.
but if there IS a pressure gradient, next step is to do an Arteriogram to specify areas of stenosis. (this is why i picked A in the choices to the question).
3. Angioplasty and stenting to treat short stenotic segments. OR
4. More extensive disease requires Bypass grafts.
(NO mention of Aspirin or Exercise)
UW on the other hand says that most patients with intermittent claudication alone remain remain stable or even improve with conservative treatment. Majority of patients are given exercise and aspirin.
-It also says that an angiogram is usually NOT required for patients with intermittent claudication if the patient has no evidence of ischemia, infection, gangrene, or loss of pulse. If surgery is not planned, a duplex arterial study may suffice. Measurement of ankle brachial index may give some idea about the extent of disease severity.
-If there is nocturnal pain, ulceration of gangrene, then an ANGIOGRAM and possible surgery may be required.
-ANGIOPLASTY and Angiogram may be done if the femoral pulses are absent. However if BOTH the femoral and popliteal pulses are present, the role of angioplasty is limited. Angioplasty is of major benefit in cases of iliac artery occlusion.
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| Markus2009
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All that i know as a first step in a patient with PAD is to do an ABI ankle-braquial index VN: 1 - 1.3 (measure the blood pressure difference in upper and lower extremities) then start the work up at this point, knowing that ABI less than 0.4 means limb isquemia.
But it is not real practice it is the USMLE so besides B: aspirin and exercise, the rest are way too agressive specially without knowing the ABI.
Angiogram is the gold standard but it is done having a plan of doing a procedure afterwards.
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| milestogo
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this pt has loss of distal pulsse bilaterally isnt aspirin and exercise too conservative.......?
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| Justice
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milestogo wrote:
this pt has loss of distal pulsse bilaterally isnt aspirin and exercise too conservative.......?
Loss if pulse is rather loss of the arterial wall compliance than complete occlusion... If that was the case, the PT would have trophic ulcers all over his feet... I guess aspirin is needed to prevent thrombosis of the narrowed vessels...
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| DrVirgo
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some hair loss of the lower legs; he has brittle toenails bilaterally.
What does that indicate?
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| Markus2009
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chronic trophic changes due to arterial insufficiency but it is not a marker for management.
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| CocaCola
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thanks for the clarification guys... aspirin and moderate exercise now makes sense!
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There is one thing we can do, and the happiest people are those who can do it to the limit of their ability. We can be completely present. We can be all here. We can give all our attention to the opportunity before us!!!
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| milestogo
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thanx justice interesting questions .......will look forward to more....pls try to give answers to all
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| DrVirgo
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If there was a choice between ABI versus ASA/Exercise which one should we pick?
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| solitarius
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You pick the ASA and the exercise.....and thats the MANAGEMENT.
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