Case+1

__MCase #1__

Mr. Pumpernickel is your next patient. He has never been seen by your vascular doctor. He is coming from an outside doctor as a referral. The only information you have about him is that he has claudication when he walks just a few blocks.


 * What history questions will you ask him?**

Michayla: Do you have rest pain? Are you diabetic? Do you have a history of vascular disease? Are you a smoker? If so, for how long? Do you have coronary artery disease? Have you had a previous stroke?

McKenna: The history questions that I would ask would be do you have claudication at rest, do you have hypertension, do you have diabetes, and do you smoke?

Madeline: Some questions I would consider asking him are how long does the claudication last after exercising? Does it go away after a couple of minutes or does it last for a while? Do you have a history of hypertension, diabetes, or previous blood clots? Do you have a history of smoking? A really important question to ask is if they are experiencing any tingling or numbness? (Anything related to the 5 P's). Also, It could be beneficial to ask them location of the pain with claudication. I would also ask them if they've ever had any previous exams done. If they have I would see if the lab I was working at had access to them because they could be useful in comparing results to see if it's progressively getting worse.

Ashley: The questions I would ask this patient would be: Do you also have pain while resting? Does your pain go away quickly after you stop walking or does it take longer? Were you/ are you a smoker? Do you have high blood pressure? Do you notice any changes in your skin color when you get this pain after walking? Do you lose some feeling or have tingling in your legs while walking?


 * What “physical” exam will you do?**

Michayla: Bilateral blood pressures, evaluate extremities, and feel for pulses McKenna: The physical exam that I would do would be to grade the pulses, check for trophic changes such as hair loss, thickened toenail, cold limb, and non healing ulcers.

Madeline: My protocol is to check blood pressures, pulses bilaterally, and look for trophic changes on the skin that could signal either arterial or venous diseases. Some trophic changes that would be important to look for are hair loss, ulcers, thickened toenails, or blue, mottled skin (or red skin that may feel warm).

Ashley: The physical exam I would do is to take bilateral pulses and blood pressures, and take note of any changes in the patient's skin color and if there are any wounds or ulcers on the patient's leg. Also make note of if there seems to be swelling or loss of hair in the extremity in question.


 * The first part of the exam will be getting ABI’s. Explain exactly how you will obtain them and then how you will calculate them:**

Michayla: I would place blood pressure cuffs around Mr. Pumpernickel's left and right arms and ankles. I would then obtain a waveform using a Doppler probe at the right dorsalis pedis artery. I would then inflate the right ankle cuff approximately 20 mmHg above his normal blood pressure and until I can not hear the artery. I would deflate the artery until I hear the first sound again. This is the blood pressure at the right dorsalis pedis artery. I would then do the same thing using the right posterior tibial artery. Next, I would find the brachial pressure using the same process but using the higher blood pressure between the dorsalis pedis artery and the right posterior tibial artery. To calculate the ankle brachial index, the higher blood pressure of the ankle is divided by the brachial pressure. The same procedure is then performed on the left side.

McKenna: The ABI is obtained by putting a cuff on the arm and leg and getting the segmental pressure of the ankle and brachial pressures. The cuff should be placed around both ankles. On the left side, the cuff should be inflated 20 mmHg above the patient's normal blood pressure. You should no longer be able to hear the pulse at this level, once you can hear the pulse again you must document the pressure at which this was heard. The same should be done for the dorsalis pedis artery and the posterior tibial artery on both sides The blood pressures in the arms should also be taken. This is

then calculated by dividing the ankle pressure by the highest brachial pressure.

Madeline: When ABI's the first you need to do is put blood pressure cuff's on the ankles and the upper arms of the patient. Next, you apply a small amount of gel to the just below the medial malleolus and on the anterior surface of the foot. These are the locations where you will use a CW probe to listen for his blood pressures. I like to start with the dorsalis pedis (anterior foot). First, I would find the vessel. Once I have found the vessel, I would inflate the cuff to around 20 mm of Hg above his normal blood pressure then slowly release the pressure. Once, I hear the vessel //pulsing// again, I would record that pressure. I would repeat that same process for the posterior tibial arteries and the bilateral brachial segmental pressures Once I have all my data, I would take the DP and the PTA pressures and divide those by the higher of the two brachial pressures. Below, I downloaded what an ABI worksheet would look like. It shows that they find two ratios. One from the PTAs and one from the DP. I do believe that they use the higher of these two values.

(Madeline) Cordio, M. (2012, November 27th). School of Diagnostic Medical Sonography Vascular I. Indirect Arterial Testing Lecture. Madison, WI, USA.

Ashley: To perform a proper ABI test, I would first place the blood pressure cuffs at the places most important to be sampling for this test. I would then put one around each ankle and then one around each forearm at the level of the elbow/brachial artery. The ankle pulse that is taken is taken at the level of the dorsalis pedis artery in the foot and the posterior tibial artery. The pressure cuff is put on the ankle and you place the CW probe at the level of the artery being sampled. The dorsalis pedis artery is sampled slightly laterally and anterior on the foot and the pressure cuff should be inflated to 20 mmHg above the normal blood pressure of the patient. After sampling both the DP and PTA (this should be done more anteriorly and medial on the ankle), compare these pressures to the brachial pressure obtained with the same method using the brachial arteries in both arms. The higher of the two ankle pressures should be used while comparing to the brachial pressure and the ankle pressure is divided by the highest brachial pressure to get the ABI index.