Transcript cases-and-questions_rangbaran_ashchi

Jeanna Rangbaran, ARNP, MSN, FNP-BC
Majdi Ashchi, DO, FACC, FSCAI, FSVM,
FABVM
This is a 39 year old Caucasian male that presents
with severe pain and discoloration in right fifth toe
along with the great toe. The pain began about three
days ago and he reported that the pain is so intense
that he cannot even sleep. He has a 40 pack year
smoking history, does not use alcohol or illicit drugs.
He had a recent arterial study from his primary care
revealing severe bilateral disease. Patient was
formerly addicted to narcotic pain medication and is
currently on Suboxone therapy. His PMH is
significant for hypertension, chronic pain and has a
family history of ischemic heart disease.
Vitals: Weight: 283 lb Height: 74 in Body Mass Index: 36.33 kg/m² Pulse: 106 (Regular) BP: 127/90
Physical Exam:
General
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Mental Status - Alert. General Appearance - Cooperative. Not in acute distress. Orientation Oriented to time, Oriented to place, Oriented to purpose and Oriented to person. Build &
Nutrition - Well nourished and Well developed.
Integumentary

Global Assessment: Examination of related systems reveals - Examination of digits and nails
reveals no abnormalities, no digital clubbing, cyanosis or petechiae.
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General Characteristics: Overall examination of the patient's skin reveals - no bruises. Color pink. Skin Moisture - normal skin moisture. Temperature - normal warmth is noted.
Head and Neck
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Neck: Carotid Arteries - Bilateral - normal upstroke and runoff.
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Thyroid :Gland Characteristics - normal size and consistency.
ENMT
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Mouth and Throat
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Oral Cavity/Oropharynx: Gingiva - no inflammation present.
Chest and Lung Exam

Inspection: Shape - Normal. Accessory muscles - No use of accessory muscles in breathing.
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Auscultation: Breath sounds: - Normal.
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Adventitious sounds: - No Adventitious sounds.
Cardiovascular
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Point of Maximal Impulse: - Normal.
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Auscultation: Rhythm - Regular. Heart Sounds - S1 WNL and S2 WNL. No S3 or S4.
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Murmurs & Other Heart Sounds: Auscultation of the heart reveals - No Murmurs.
Abdomen
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Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No
Palpable abdominal masses.

Liver: Other Characteristics - No Hepatomegaly.

Spleen: Other Characteristics - No Splenomegaly.
Peripheral Vascular
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Lower Extremity:
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Palpation: Femoral pulse - Bilateral - Normal. Dorsalis pedis pulse - Bilateral - Absent.
Edema - Bilateral - No edema. Rutherford Classification - Stage 5 - Ischemic ulceration not
exceeding ulcer of the digits of the foot (RIGHT fifth is blue, cold . Dusky, bluish fourth
digit with poor pulses.).
Neurologic
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Motor: - Normal.
Leriche syndrome:
s/p aortoiliac Endo graft placement.
Educated on antibiotics before minor procedures
or dental procedures.
Atheroembolism of foot:
right foot, right fifth toe and first toe; continue
with podiatry care
The prevalence of PAD increases progressively
with age, beginning after age 40. As a result, PAD
is growing as a clinical problem due to the aging
population in the United States and other
developed countries. As such, a standard review
during the examination of older patients should
always include questions related to a history of
walking impairment, extremity pain that might be
due to ischemia, and the presence of nonhealing
wounds.
●Does the patient have any pain with ambulation? If so, how far can the
patient walk before the pain occurs? Does the pain cause the patient to
stop walking? If so, after how much time is the patient able to resume
walking? Does the pain recur after a similar walking distance? Has the
patient’s ability to walk diminished over time or altered the patient’s
lifestyle in any way?
●Does the patient experience any pain in the extremity that wakens them
from sleep? If so, where is the pain located? Is the pain relieved once the
foot is hung over the side of the bed? Does pain cause the patient to sleep
sitting in a chair?
●Has the patient noticed any non-healing wounds or ulcers on the toes? If
so, how long have the wounds or ulcers been present? If wounds have
occurred in the past, what measures were used to promote healing?
●Is the patient known to have PAD? If so, has the patient undergone any
prior interventions to manage PAD, or other arterial disease?
This is a 70-year-old female with the past medical history significant for
coronary artery disease, hypertension, dyslipidemia, anxiety, who presented
with acute onset of back pain radiating down to her both lower extremities.
The patient was seen in the Emergency Room and there was a concern about
elevated cardiac enzymes. The patient was seen by Cardiology and initially,
she was treated with pain medication and muscle relaxant by the primary
team. Progressively, during her stay in the hospital, she was complaining of
worsening weakness of her lower extremities, that was of concern and MRI of
the spine was ordered revealing AV malformation at T11-L2 level. The case
was then transferred Dr. Rabih Tawk, endovascular neurosurgery that
specializes in Spine arteriovenous malformations at Mayo Clinic. The patient
during her stay in the hospital was on IV heparin for her elevated cardiac
enzymes and repeat cardiac enzymes were negative and her EKG showed no
changes and there was no concern of any acute MI.
She was paralyzed from the waist down from an AV malformation at T11-L2
level first diagnosed at OPMC and then subsequently underwent surgical
correction at Mayo Clinic. The patient was on clopidogrel. She is now
undergoing Brooks PT, OT currently and has started to regain some mobility.
Vitals: Weight: 125 lb Height: 65 in Body Mass Index: 20.8 kg/m² Pulse: 66 (Regular) BP: 129/69
Left Arm, Standard)
(Sitting,
Physical Exam
General

Mental Status - Alert. General Appearance - Cooperative. Not in acute distress.
Integumentary

Global Assessment: Examination of related systems reveals - Examination of digits and nails reveals
no abnormalities, no digital clubbing, cyanosis or petechiae.

General Characteristics: Overall examination of the patient's skin reveals - no bruises. Color - pink.
Skin Moisture - normal skin moisture. Temperature - normal warmth is noted.
Head and Neck

Neck: Carotid Arteries - Bilateral - normal upstroke and runoff.
Eye
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Sclera/Conjunctiva - Bilateral - Normal.
ENMT

Mouth and Throat: Oral Cavity/Oropharynx: Gingiva - no inflammation present.
Chest and Lung Exam

Inspection: Shape - Normal. Accessory muscles - No use of accessory muscles in breathing.

Auscultation: Breath sounds: - Normal.

Adventitious sounds: - No Adventitious sounds.
Cardiovascular

Inspection: BP In 2+

Palpation/Percussion: Point of Maximal Impulse: - Normal.

Auscultation: Rhythm - Regular. Heart Sounds - S1 WNL and S2 WNL. No S3 or S4.

Murmurs & Other Heart Sounds: Auscultation of the heart reveals - No Murmurs.
Abdomen

Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Palpable
abdominal masses.
Peripheral Vascular

Lower Extremity: Palpation: Femoral pulse - Bilateral - Normal. Dorsalis pedis pulse - Bilateral - Normal.
Edema - Bilateral - No edema.

Note: palpable fem-fem bypass noted on exam. has strong +2 DP pulses bilaterally. no wounds or ulcerations.
both feet warm to touch. right PT pulse +2, left PT pulse difficult to palpate.
Neurologic

Motor: Strength: 1/5 minimal contraction - Left Upper Extremity. 0/5 no motion palpable - Right Lower
Extremity.
AV malformation, acquired
 T11-L1 s/p surgical correction with Dr. Rabih
Tawk at Mayo
Coronary artery disease
Plavix (clopidogrel) is now contraindicated for
this patient. CAD is stable. No active angina. ECG
stable. Continue recommendation of aggressive
medical therapy and risk factor modification.
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Developmental venous anomalies or venous
angiomas are the most common and consist of a
radially arranged configuration of medullary
veins.
They are usually identified on magnetic resonance
imaging (MRI). Cerebral angiography is
considered the gold standard for diagnosis.
Usually an incidental finding, rarely present with
seizures or hemorrhage. After diagnosis,
hemorrhage is unusual.
Most patients are followed without intervention,
rarely surgery is required for hemorrhage or
intractable epilepsy.
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Flemming KD, Link MJ, Christianson TJ, Brown RD Jr. Neurology.
2012 Feb;78(9):632-6. Epub 2012 Feb 1. Prospective hemorrhage
risk of intracerebral cavernous malformations.
Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss
L, Golzarian J, Gornik HL, Jaff MR, Moneta GL, Olin JW, Stanley
JC, White CJ, White JV, Zierler RE, American College of
Cardiology Foundation Task Force, American Heart Association
Task Force; J Am Coll Cardiol. 2013 Apr;61(14):1555-70. Epub 2013
Mar 6. Management of patients with peripheral artery disease
(compilation of 2005 and 2011 ACCF/AHA Guideline
Recommendations): a report of the American College of
Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines.