1. What are the likely sources of his calf pain and his hip pain?

-Due to his weight (261 lbs.) and history of right femoral fracture 20 years ago that is causing
hip pain.

2. S.P. has several risk factors for PAD. From his history, list two risk factors, and explain
the reason they are risk factors.
-HTN- It causes excess stress on blood vessel walls and turbulent blood flow. Over time, this
excess force causes blood vessel damage, and increases the risk of PAD.
-Smoking- Smoking irritates and narrows blood vessels, contributes to the buildup of arterial
plaque, and raises heart rate and blood pressure.

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

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

5. What is the purpose of the daily aspirin listed in S.P.'s current medication?
-Aspirin acts as a platelet aggregation inhibitor and is used to prevent
thromboembolism.

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?

- Instruct him not to smoke for at least 30 minutes before the test because nicotine
creates constriction of the peripheral arteries and alters the test results.
- Instruct him to wear clothes that are easy to remove or pull up or down because
blood pressure (BP) cuffs will be placed on both arms and legs. He will need to lie
still during the test.
- Inform him that the test is painless, takes about 30 minutes, and that he can eat
 before the test.

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 medication 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 a ratio that is derived by dividing the ankle BP by the brachial BP. An ABI of
less than 0.9 in either leg is diagnostic of PAD. S.P.’s right leg shows a lower ABI, which
means the disease is worse in his right leg. His results indicate moderate to severe PAD.

8. You counsel S.P. on risk factor modification. What would you address, and why?
- Quit smoking: Smoking cessation reduces the progression of the disease.
- Exercise: Exercise decreases vascular resistance and enhances blood flow to the
exercised extremity.
- Control BP
- Comply with medication regimen

9. How will the physical therapy help?

-Exercise may improve collateral circulation to the limb. Exercise will be started slowly
and gradually increased. S.P. will be instructed to walk to the point of claudication, stop,
rest, then resume to walk a little farther. As collateral circulation improves, the
distances walked will improve. It will take persistence on S.P.’s part to continue this
exercise.

10. In addition to risk factor modification, what other measures to improve tissue perfusion
or to prevent skin damage should you recommend to S.P.?
-Ensure adequate hydration to prevent increased blood viscosity.
-Do not use heating pads and hot water bottles—the skin has poor circulation and is
subject to injury.
-Avoid crossing the legs, especially at the knee; it will further impair circulation.
-Take steps to prevent trauma to tissue; for example, wear socks or protective footwear
at all times (don’t go barefoot).
-Use minimal pressure when applying lotions or creams because excessive pressure can
damage the skin. Tissue oxygenation is already compromised because of impaired
arterial circulation. Any damage to this tissue can result in ulceration.

11. 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?
-Elevating the legs and using compression stockings are common treatments for venous
problems in the lower extremities. S.P. does not have that problem; he has arterial
problems, and wearing compression stockings or socks with tight banding could further
impair his circulation.
 -His legs should be kept in a slightly dependent position to allow gravity to help with
circulation.

12. 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?
-The risk for bleeding.

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.