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Jeanna Rangbaran, ARNP, MSN, FNP-BC Majdi Ashchi, DO, FACC, FSCAI, FSVM, FABVM This is a 39 year old Caucasian male that presents with severe pain and discoloration in right fifth toe along with the great toe. The pain began about three days ago and he reported that the pain is so intense that he cannot even sleep. He has a 40 pack year smoking history, does not use alcohol or illicit drugs. He had a recent arterial study from his primary care revealing severe bilateral disease. Patient was formerly addicted to narcotic pain medication and is currently on Suboxone therapy. His PMH is significant for hypertension, chronic pain and has a family history of ischemic heart disease. Vitals: Weight: 283 lb Height: 74 in Body Mass Index: 36.33 kg/m² Pulse: 106 (Regular) BP: 127/90 Physical Exam: General Mental Status - Alert. General Appearance - Cooperative. Not in acute distress. Orientation Oriented to time, Oriented to place, Oriented to purpose and Oriented to person. Build & Nutrition - Well nourished and Well developed. Integumentary Global Assessment: Examination of related systems reveals - Examination of digits and nails reveals no abnormalities, no digital clubbing, cyanosis or petechiae. General Characteristics: Overall examination of the patient's skin reveals - no bruises. Color pink. Skin Moisture - normal skin moisture. Temperature - normal warmth is noted. Head and Neck Neck: Carotid Arteries - Bilateral - normal upstroke and runoff. Thyroid :Gland Characteristics - normal size and consistency. ENMT Mouth and Throat Oral Cavity/Oropharynx: Gingiva - no inflammation present. Chest and Lung Exam Inspection: Shape - Normal. Accessory muscles - No use of accessory muscles in breathing. Auscultation: Breath sounds: - Normal. Adventitious sounds: - No Adventitious sounds. Cardiovascular Point of Maximal Impulse: - Normal. Auscultation: Rhythm - Regular. Heart Sounds - S1 WNL and S2 WNL. No S3 or S4. Murmurs & Other Heart Sounds: Auscultation of the heart reveals - No Murmurs. Abdomen Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Palpable abdominal masses. Liver: Other Characteristics - No Hepatomegaly. Spleen: Other Characteristics - No Splenomegaly. Peripheral Vascular Lower Extremity: Palpation: Femoral pulse - Bilateral - Normal. Dorsalis pedis pulse - Bilateral - Absent. Edema - Bilateral - No edema. Rutherford Classification - Stage 5 - Ischemic ulceration not exceeding ulcer of the digits of the foot (RIGHT fifth is blue, cold . Dusky, bluish fourth digit with poor pulses.). Neurologic Motor: - Normal. Leriche syndrome: s/p aortoiliac Endo graft placement. Educated on antibiotics before minor procedures or dental procedures. Atheroembolism of foot: right foot, right fifth toe and first toe; continue with podiatry care The prevalence of PAD increases progressively with age, beginning after age 40. As a result, PAD is growing as a clinical problem due to the aging population in the United States and other developed countries. As such, a standard review during the examination of older patients should always include questions related to a history of walking impairment, extremity pain that might be due to ischemia, and the presence of nonhealing wounds. ●Does the patient have any pain with ambulation? If so, how far can the patient walk before the pain occurs? Does the pain cause the patient to stop walking? If so, after how much time is the patient able to resume walking? Does the pain recur after a similar walking distance? Has the patient’s ability to walk diminished over time or altered the patient’s lifestyle in any way? ●Does the patient experience any pain in the extremity that wakens them from sleep? If so, where is the pain located? Is the pain relieved once the foot is hung over the side of the bed? Does pain cause the patient to sleep sitting in a chair? ●Has the patient noticed any non-healing wounds or ulcers on the toes? If so, how long have the wounds or ulcers been present? If wounds have occurred in the past, what measures were used to promote healing? ●Is the patient known to have PAD? If so, has the patient undergone any prior interventions to manage PAD, or other arterial disease? This is a 70-year-old female with the past medical history significant for coronary artery disease, hypertension, dyslipidemia, anxiety, who presented with acute onset of back pain radiating down to her both lower extremities. The patient was seen in the Emergency Room and there was a concern about elevated cardiac enzymes. The patient was seen by Cardiology and initially, she was treated with pain medication and muscle relaxant by the primary team. Progressively, during her stay in the hospital, she was complaining of worsening weakness of her lower extremities, that was of concern and MRI of the spine was ordered revealing AV malformation at T11-L2 level. The case was then transferred Dr. Rabih Tawk, endovascular neurosurgery that specializes in Spine arteriovenous malformations at Mayo Clinic. The patient during her stay in the hospital was on IV heparin for her elevated cardiac enzymes and repeat cardiac enzymes were negative and her EKG showed no changes and there was no concern of any acute MI. She was paralyzed from the waist down from an AV malformation at T11-L2 level first diagnosed at OPMC and then subsequently underwent surgical correction at Mayo Clinic. The patient was on clopidogrel. She is now undergoing Brooks PT, OT currently and has started to regain some mobility. Vitals: Weight: 125 lb Height: 65 in Body Mass Index: 20.8 kg/m² Pulse: 66 (Regular) BP: 129/69 Left Arm, Standard) (Sitting, Physical Exam General Mental Status - Alert. General Appearance - Cooperative. Not in acute distress. Integumentary Global Assessment: Examination of related systems reveals - Examination of digits and nails reveals no abnormalities, no digital clubbing, cyanosis or petechiae. General Characteristics: Overall examination of the patient's skin reveals - no bruises. Color - pink. Skin Moisture - normal skin moisture. Temperature - normal warmth is noted. Head and Neck Neck: Carotid Arteries - Bilateral - normal upstroke and runoff. Eye Sclera/Conjunctiva - Bilateral - Normal. ENMT Mouth and Throat: Oral Cavity/Oropharynx: Gingiva - no inflammation present. Chest and Lung Exam Inspection: Shape - Normal. Accessory muscles - No use of accessory muscles in breathing. Auscultation: Breath sounds: - Normal. Adventitious sounds: - No Adventitious sounds. Cardiovascular Inspection: BP In 2+ Palpation/Percussion: Point of Maximal Impulse: - Normal. Auscultation: Rhythm - Regular. Heart Sounds - S1 WNL and S2 WNL. No S3 or S4. Murmurs & Other Heart Sounds: Auscultation of the heart reveals - No Murmurs. Abdomen Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Palpable abdominal masses. Peripheral Vascular Lower Extremity: Palpation: Femoral pulse - Bilateral - Normal. Dorsalis pedis pulse - Bilateral - Normal. Edema - Bilateral - No edema. Note: palpable fem-fem bypass noted on exam. has strong +2 DP pulses bilaterally. no wounds or ulcerations. both feet warm to touch. right PT pulse +2, left PT pulse difficult to palpate. Neurologic Motor: Strength: 1/5 minimal contraction - Left Upper Extremity. 0/5 no motion palpable - Right Lower Extremity. AV malformation, acquired T11-L1 s/p surgical correction with Dr. Rabih Tawk at Mayo Coronary artery disease Plavix (clopidogrel) is now contraindicated for this patient. CAD is stable. No active angina. ECG stable. Continue recommendation of aggressive medical therapy and risk factor modification. Developmental venous anomalies or venous angiomas are the most common and consist of a radially arranged configuration of medullary veins. They are usually identified on magnetic resonance imaging (MRI). Cerebral angiography is considered the gold standard for diagnosis. Usually an incidental finding, rarely present with seizures or hemorrhage. After diagnosis, hemorrhage is unusual. Most patients are followed without intervention, rarely surgery is required for hemorrhage or intractable epilepsy. Flemming KD, Link MJ, Christianson TJ, Brown RD Jr. Neurology. 2012 Feb;78(9):632-6. Epub 2012 Feb 1. Prospective hemorrhage risk of intracerebral cavernous malformations. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L, Golzarian J, Gornik HL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE, American College of Cardiology Foundation Task Force, American Heart Association Task Force; J Am Coll Cardiol. 2013 Apr;61(14):1555-70. Epub 2013 Mar 6. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.