1. Left Leg Pain Brian Lewis M.D. Assistant Professor of Surgery Medical College of Wisconsin

2. 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.

3. History What other points of the history do you want to know?

4. History, Ms. Doe Consider the following: Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors: Associated signs/symptoms Pertinent PMH ROS MEDS Relevant Family Hx. Relevant Social Hx.

5. 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

6. 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

7. What is your Differential Diagnosis?

8. 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

9. Physical Examination What specifically would you look for?

10. 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 bruitsPulses: normal radial, femoral, carotid bilaterally; absent popliteal, DP and PT pulses bilaterally Chest: clear bilaterallyNeuromuscular: neuropathy in both feet CV: RRR, no murmursSkin/Soft Tissue: skin shiny on bilateral legs, no wounds, legs non-tender to palpation Abd: Soft, nontender, no masses Remaining Examination findings non-contributory

11. Differential Diagnosis Would you like to update your differential?

12. Studies (Labs, X-rays etc.) What would you obtain?

13. Studies, Ms. Doe Ankle-brachial indices Right:0.98 Left:Incompressible Toe Pressures Right: 60 Left: <20

14. ABI Can anyone describe how ankle brachial indices are performed? What represents normal range? Abnormal? What conditions might falsely elevate the number?

15. Lab Studies ordered, Ms. Doe CBC:Within normal limits LFTsWithin normal limits PT/PTTWithin normal limits ElectrolytesWithin normal limits UrinalysisWithin normal limits Lipid PanelWithin normal limits Hb A1C7.8 These were obtained by PMD 6 weeks ago

16. Lab Results, Discussion

17. Interventions at this point?

18. 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

19. What next?

20. Next Steps How would you schedule follow-up? Any studies at time of follow-up?

21. 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

22. 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

23. What studies would you obtain? Ankle-brachial indices Right:0.98 Left:Incompressible Toe Pressures Right: 60 Left:<20 Anything else ?

24. Angiogram

31. How would you describe the findings?

32. What would you do now?

33. Management Options Observe Surgery Options? What workup would be required? Endovascular management Options? What are some strengths and limitations of the various options?

34. Post op Management Discuss routine post op Discuss most common complications Mention any rare findings

35. 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%

36. QUESTIONS ??????

37. 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

38. Acknowledgment ASSOCIATION FOR SURGICAL EDUCATION 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: feedbackPPTM@surgicaleducation.com