SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Emmanuel Katada

SUBMITTED BY: de los Santos, Rosheil Mae C. Ditti, Fatimah Al-Zahra Divinagracia, Joshua
LukeDocto, Christian Dave
REPRESENTATIVE CASE
IDENTIFYING DATA: Male, 87 Years old, retired teacher, Roman Catholic, married
CHIEF COMPLAINT: Bilateral leg pain
HISTORY OF PRESENT ILLNESS:
6 months PTA, intermittent crampy leg pain started aggravated when walking associated with occasional back pain,
no swelling noted. Alleviated with rest.
Upon admission, bilateral leg pain was noted. Pain scale in the calf area 6/10. Duration of pain is related to activity.
PAST MEDICAL HISTORY:
(+) Asthma, Hypertention (controlled), DM (controlled), had history of spondylosis 10 years ago
PERSONAL AND SOCIAL HISTORY:
Patient is vegetarian, adequate fluid intake, sedentary lifestyle (walks in the compound).
(+) Smoker, 20 pack years until 2 years ago
(+) Moderate alcohol intake
(-) Illicit drug use
PHYSICAL EXAMINATION
Vital Signs:
BP: 150/90 mmHg
HR: 80/min
RR: 20/min
Temp: 37.6 C
BMI: Within Normal
Skin: Senile loss of turgor, dry skin, no bruises
HEENT: All normal
Neck: All normal
Pulmonary: All normal
Cardiovascular: All normal
Abdomen: All normal
Genitourinary:All normal
Extremities: Lower extremities: Symmetrical, bilateral muscle atrophy, no swelling, no ulcer, no discoloration; hair
loss in legs and toes; no deformities. Strong femoral and popliteal pulse; Dorsalis pedis and posterior tibial pulses
are faintly palpable. (-) Homans sign; warm legs but feet are cold. Capillary refill time: 4 seconds. (-) bruits.
Normoactive reflexes, (+) femoral stretch pain
II. PRIMARY IMPRESSION
DIAGNOSIS
RULE IN
RULE OUT
III. DIFFERENTIAL DIAGNOSIS
DIAGNOSES

RULE IN

IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS

PATIENT
NORMAL
LAB. TEST
INTERPRETATION/NECESSITY
RESULTS
VALUES
HEMATOLOGY
Hemoglobin
WBC
Segmenters
Lymphocyte
Monocyte
Eosinophils
Platelet count
MCV
MCHC

BLOOD CHEMISTRY
Serum sodium
Serum

RULE OUT

AVAILABILI
TY

COST

Poratssium
SGPT
Serum Albumin
CRP
Total cholesterol
Creatinine
BUN
URINALYSIS
Specific gravity
pH
Protein
Blood
Pus cells
RBC
STOOL EXAM
Color
Consistency
Pus cells
RBC
Amoeba
trophozoite
Amoeba cyst
Yeast cells
Fat globules
Ascaris
PATHOPHYSIOLOGY
V. THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS
1. Bilateral leg pain, (+) Femoral Stretch pain
2. Occasional Back pain
3. Ischemic Rest Pain
4. Dry Skin
5. Muscle atrophy
6. HPN, DM

THERAPEUTIC OBJECTIVES
To treat underlying cause of the bilateral leg pain
To alleviate back pain
To restore normal blood flow to the lower extremities
Prevent complications caused by ischemia such as
gangrene
5. Prevent breakage of skin barrier due to dryness.
Provide adequate hydration
6. Control patients DM and Hypertension
7. Restore/improve body strength and function
ADVICE AND INFORMATION
1. Educate patient and family about his condition: possible etiology, risk factors, course of disease, signs and
symptoms, complications if left untreated, prognosis and medical options for treatment including its
benefits, side effects, risk and alternatives. Increasing patients knowledge about his condition to improve
medical compliance and assist in symptom management.
2. Encourage family involvement, including their understanding and participation in the plan of care.
Participation can include supporting the patient in risk-factor management and rehabilitation therapies for
regaining physical function as well as providing psychosocial support.
3. A daily walking program of 45-60 minutes is recommended. The patient walks until claudication pain
occurs, rests until the pain subsides, and then repeats the cycle. Regular exercise is believed to condition
muscles so that they work more efficiently (ie, extract more blood) and to increase collateral vessel
formation.
PHARMACOLOGIC MANAGEMENT
DRUG NAME

EFFICACY

1.
2.
3.
4.

SAFETY

SUITABILITY

P-DRUGS
DRUG NAME

EFFICACY

SAFETY

SUITABILITY

COST

VI. MONITORING AND FOLLOW-UP

1. Patients who are treated medically should be seen every 4-6 months to assess the effects of therapy.
2. Any changes in walking distance, or exercise performance should be reviewed.
3. Hypertension and diabetes should be controlled if necessary.
4. Repeat pulse examination should be performed and the ABI measured. If the patients symptoms are
worsening, intervention and referral to a vascular surgeon may be warranted.

Patient:
Age: > 65 years old
Gender: Male
History of Smoking
Hypertension (controlled)
Sedentary Lifestyles
Diabetes Mellitus (controlled)

NONMODIFIABLE:
Age: > 65 years old
Gender: Male
Familial Disposition
MODIFIABLE:
Smoking
Hypertension
Diet (contributing to hyperlipidemia
Obesity
Sedentary Lifestyles
Diabetes Mellitus
Development of fatty streaks of lipids
Deposited in the intima of arterial walls
Injury to the vascular endothelium
Attracts Inflammatory cells

Macrophages infiltrate the injured vascular endothelium

Releases biochemical substances, damages endothelium

Resulting to attraction of platelets and initiates clotting

Excessive accumulation of platelets/clotting

Thrombus formation
Emboli
Occlusion of arterial lumen

Peripheral Arterial Occlusion Disease

pulses are faintly palpable, decreased hair growth/hair loss,warm legs

Ischemia
but feet are cold. Capillary refill time: 4 seconds
Ischemic Necrosis

LEGEND:
Risk Factors
Pathophysiology
Manifestations
Disease Condition