Question: S.P. Is A 68-year-old Retired Painter Who Is Experiencing Right Leg Calf Pain. The Pain Began Approximately 2 Years Ago But Has Become Significantly Worse In The Past 4 Months. The Pain Is Precipitated By Exercise And Is Relieved With Rest. Two Years Ago, S.P. Could Walk 2 City Blocks Before Having To Stop Because Of Leg Pain. Today, He Can Barely Walk …

S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately 2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise and is relieved with rest. Two years ago, S.P. could walk 2 city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. S.P. has smoked 2 to 3 packs of cigarettes per day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN), peripheral artery disease (PAD), and osteoarthritis. Surgical history includes quadruple coronary artery bypass graft 3 years ago. He has had no further symptoms of cardiopulmonary disease since that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed, continues to eat anything he wants, and continues to smoke 2 to 3 PPD. Other surgical history includes open reduction and internal fixation of a right femoral fracture 20 years ago. S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care provider. As you take his vital signs, he tells you that in addition to the calf pain, he is experiencing right hip pain that gets worse with exercise, the pain does not go away promptly with rest, some days are worse than others, and his condition is not affected by a resting position. Chart View General Assessment Weight Height BP Pulse Respiratory rate Temperature Laboratory Testing (Fasting) Cholesterol Triglycerides HDL LDL 261 lb (118.4 kg) 5 ft, 10 in (178 cm) 163/91 82 16 98.4°F (36.9° C) 239 mg/dL (6.2 mmol/L) 150 mg/dL (1.69 mmol/L) 28 mg/dL (0.73 mmol/L) 181 mg/dL (4.69 mmol/L) Current Medications Ramipril (Altace) Metoprolol (Lopressor) Aspirin Atorvastatin (Lipitor) 10 mg daily 25 mg twice a day 81 mg daily 20 mg daily S.P.’s ABl results showed 0.43 right (R) leg and 0.59 left (L) leg. His primary care provider discusses these results with him and decides to wait 2 months to see whether his symptoms improve with drug changes and risk factor modification before deciding about surgical intervention. S.P. receives a prescription for clopidogrel (Plavix) 75 mg daily and is told to discontinue the daily aspirin. In addition, S.P. receives a consultation for physical therapy. 7. What do these ABI results indicate? 8. You counsel S.P. on risk factor modification. What would you address, and why? 9. You provide teaching on proper care of his feet and lower extremities, then use “teach-back” to assess S.P.’s learning. Which statements by S.P. indicate a need for further instruction? Select all that apply. a. “I can go barefoot in the house, but not outside.” b. “I will wear shoes that are roomy and protective.” c. “I will avoid exposing my feet to extremes of heat and cold.” d. “I will soak my feet in water once a day to make sure they are clean.” e. “I will put lotion on my feet and lower legs, but not in between the toes.” 10. How will the physical therapy help? 11. In addition to risk factor modification, what other measures to improve tissue perfusion or prevent skin damage should you recommend to S.P.? 12. S.P. tells you his neighbor told him to keep his legs elevated higher than his heart and asks for compression stockings to keep swelling down in his legs. How should you respond? 13. S.P. has been on aspirin therapy but now will be taking clopidogrel instead. What is the most important aspect of patient teaching that you will emphasize with this drug?