Transcript Leg Pain Claudication

Left Leg Pain
Brian Lewis M.D.
Assistant Professor of Surgery
Medical College of Wisconsin
Ms. Doe
 Ms. Doe is a 55-year-old woman, c/o
progressive left leg pain. She is referred by her
PMD to clinic today for evaluation of left leg
pain. The right leg gives her no trouble.
History
What other points of the history do
you want to know?
History, Ms. Doe
Consider the following:
• Characterization of
• Associated signs/symptoms
Symptoms:
• Temporal sequence
• Alleviating /
Exacerbating factors:
• Pertinent PMH
•
ROS
•
MEDS
• Relevant Family Hx.
• Relevant Social Hx.
History, Ms. Doe
 Characterization of symptoms
• Pain occurs in left calf with walking, worsening over time.
Feels like a “cramp”. Limits her ability to play with her
grandkids.
 Temporal sequence
• Only occurs with walking
• Reproducible at the same distance
 Alleviating / Exacerbating factors
• Worse with walking especially up hill or stairs
• Goes away when she stops
History, Ms. Doe
 Associated signs/symptoms:
• No pain in foot when in bed, though both feet tend to be “numb”
• No wounds on feet
 Pertinent PMH:
• ROS: HTN, IDDM, Hyperlipidemia, no hx of DVT/clotting disorders
• MEDS: Insulin, Amitryptiline, Atorvostatin, Lisinopril, Neurontin
 Relevant Family Hx.
• Positive for CAD, Diabetes
 Relevant Social Hx.
• Smokes cigarettes ½ ppd for 40 years
What is your Differential Diagnosis?
Differential Diagnosis
Based on History and Presentation










Muscle strain
Dehydration
Drug reaction – statins
Tendonitis
Deep venous thrombosis
Claudication
Arthritis
Varicose veins
Malignancy
Sciatic nerve pain
Physical Examination
What specifically would you look for?
Physical Examination, Ms. Doe
 Vital Signs: T 98.6° F, P 82, BP 173/81, RR 16
 Appearance: Healthy, pleasant, non distressed
 Relevant Exam findings for a problem focused assessment
HEENT: normal, no bruits
Pulses: normal radial, femoral,
carotid bilaterally; absent
popliteal, DP and PT pulses
bilaterally
Chest: clear bilaterally
Neuromuscular: neuropathy in
both feet
CV: RRR, no murmurs
Skin/Soft Tissue: skin shiny on
bilateral legs, no wounds, legs
non-tender to palpation
Abd: Soft, nontender, no masses Remaining Examination findings
non-contributory
Differential Diagnosis
Would you like to update your differential?
Studies (Labs, X-rays etc.)
What would you obtain?
Studies, Ms. Doe
 Ankle-brachial indices
• Right: 0.98
• Left: Incompressible
 Toe Pressures
• Right: 60
• Left: <20
ABI
 Can anyone describe how ankle brachial indices
are performed?
 What represents normal range? Abnormal?
 What conditions might falsely elevate the
number?
Lab Studies ordered, Ms. Doe
These were obtained by PMD 6 weeks ago
CBC:
Within normal limits
LFT’s
PT/PTT
Electrolytes
Within normal limits
Within normal limits
Within normal limits
Urinalysis
Within normal limits
Lipid Panel
Hb A1C
Within normal limits
7.8
Lab Results, Discussion
Interventions at this point?
How would you manage this patient?
 Risk factor control
− BP control
− Lower lipids/cholesterol
− Blood sugar control
− Smoking cessation
− β-blockers
− ASA
 Exercise program
 Medications
− Pentoxifylline
− Cilostazol
What next?
Next Steps
 How would you schedule follow-up?
 Any studies at time of follow-up?
Ms. Doe calls the office 15 months later
complaining of worsening symptoms in left leg.
 Now pain when she walks only a few steps
 Now has an open wound on the left first toe
• States the wound has been present for weeks and
is only getting worse
Physical Examination
 PE is unchanged with exception that there is a
swollen left first toe with an open 1cm x 1cm
necrotic based wound on the medial aspect
 The toe is extremely tender
 There is no drainage from the wound
What studies would you obtain?
 Ankle-brachial indices
• Right: 0.98
• Left: Incompressible
 Toe Pressures
• Right: 60
• Left: <20
Anything else ?
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
 How would you describe the findings?
What would you do now?
Management Options
 Observe
 Surgery
• Options?
• What workup would be required?
 Endovascular management
• Options?
 What are some strengths and limitations of the
various options?
Post op Management
 Discuss routine post op
 Discuss most common complications
 Mention any rare findings
Discussion
 Additional teaching points
• Disease process
− Claudication
•
•
•
•
1% - 2% of population <50 yo
Up to 5% of population 50 – 70 yo
Up to 10% greater then 70 yo
At 10 years only 25% have symptomatic disease
progression
− Limb-threatening ischemia
• Develops in approximately 1 of every 100 claudicators
• Obtaining consultants
− High incidence of CAD associated with PVD
• Approximate percent with no or mild/mod CAD
40%
• Approximate percent with advanced or severe CAD
60%
QUESTIONS ??????
Summary
 Intervention for infra-inguinal vascular disease is most
often reserved for ?
• Rest pain
• Tissue loss
 Fix in-flow first
 Below the inguinal level vein is typically the preferred
conduit
 The role for endovascular management is evolving
 Vascular disease in a single territory is often a marker
for generalized vascular disease
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]