Case+5

__Case #5__

Ms. Wise is your next patient. The nurse has completed her ABI’s for you so you can get started with the indirect study. The doctor has not ordered exercise ABI’s just the standard indirect arterial study and it’s up to you to determine if you need to add the duplex portion. This is what you get: Jess: The doctor didn't order the exercise ABI because he could already see that there were abnormal results without doing that portion of the exam.
 * Why did the doctor decide not to do the exercise ABI’s?**

Danielle: Just by looking at these waveforms, you can tell that there is disease in the right leg and maybe some disease distally in the left leg. You wouldn't have to exercise this patient because you are already seeing the abnormal waveforms.

Tatyana: The doctor did not see an indication for the exercise portion of the exam as it was obvious (by the results of PVR's and segmental pressures) this patient has a severe arterial disease in his right lower extremity and some disease in the left.

Jen: I agree with each of you. There is clearly disease of the right side based on the PVR and segmental pressures. Exercise ABI's would have been unnecessary and even dangerous for the patient because of the decreased pressures on the right with simply resting.

Jess: This is a multilevel disease on the right leg and also has disease around the knee to calf area on the left leg.
 * Where do suspect the disease? Single level or multilevel?**

Danielle: After looking at the waveforms, I predict that there is a multi-level disease in the right leg and maybe single level disease on the left leg at the ankle.

Tatyana: This patient has a multilevel disease the right thigh, and right calf ; also some pathology at the level of the left ankle and foot.

Jen: I would say the right side has multilevel disease because even though the pressure drops the biggest from the bifurcation to the thigh region, then says about the same down the leg, there is a difference of more than 20 mmHg with the contralateral side down the entire leg. As for the left side, I am guessing there is disease in the anterior tibial because of the significant decrease in pressures in the ATA and DP compared to the PTA on that side.

Jess: Yes, we would need to scan this patient to determine the exact location of the disease.
 * Will you scan this patient?**

Danielle: Yes, we would want to scan them to pin point where the disease is actually located in each leg and also to see the severity of the disease in each leg.

Tatyana: Yes, I agree with Jess and Danielle, we would scan this patient to see the exact level and severity of the pathology.

Jen: Scanning the patient would be beneficial. On the right side, I would be MOST concerned with the region from the iliac bifurcation through the high thigh because that's where the biggest drop of pressures occurs. Also, I would be interested in looking at the anterior arterial circulation in the calf to see if any stenosis or narrowing is seen there.