STUDY - Technical - New Dacian's Medicine
Intermittent
claudication (Classical / Allopathic Medicine)
Most common in the
legs, intermittent claudication is cramping limb pain brought
on by exercise and relieved by 1 to 2 minutes of rest. This
pain may be acute or chronic; when acute, it may signal acute
arterial occlusion. Intermittent claudication is most common
in men ages 50 to 60 with a history of diabetes mellitus,
hyperlipidemia, hypertension, or tobacco use. Without
treatment, it may progress to pain at rest. With chronic
arterial occlusion, limb loss is uncommon because collateral
circulation usually develops.
With occlusive
artery disease, intermittent claudication results from an
inadequate blood supply. Pain in the calf (the most common
area) or foot indicates disease of the femoral or popliteal
arteries; pain in the buttocks and upper thigh, disease of the
aortoiliac arteries. During exercise, the pain typically
results from the release of lactic acid due to anaerobic
metabolism in the ischemic segment secondary to obstruction.
When exercise stops, the lactic acid clears and the pain
subsides.
Intermittent
claudication may also have a neurological cause: narrowing of
the vertebral column at the level of the cauda equina. This
condition creates pressure on the nerve roots to the lower
extremities. Walking stimulates circulation to the cauda
equina, causing increased pressure on those nerves and
resulting pain.
ALERT:
If the patient has sudden intermittent claudication with severe or aching leg pain at rest:
- check the leg's temperature and color and palpate pulses
- ask about numbness and tingling
- don't elevate the leg; protect it and let nothing press on it
- arrange for an immediate surgical consultation.
If the patient has chronic intermittent claudication, perform a focused assessment.
If the patient has sudden intermittent claudication with severe or aching leg pain at rest:
- check the leg's temperature and color and palpate pulses
- ask about numbness and tingling
- don't elevate the leg; protect it and let nothing press on it
- arrange for an immediate surgical consultation.
If the patient has chronic intermittent claudication, perform a focused assessment.
HISTORY:
Ask the patient how far he can walk before pain occurs and how long he must rest before it subsides. Can he walk less far now than before, or does he need to rest longer? Does the pain-rest pattern vary? Has this symptom affected his lifestyle?
Review the patient's medical history for risk factors of atherosclerosis, such as smoking, diabetes, hypertension, and hyperlipidemia.
Ask the patient about associated signs and symptoms, such as paresthesia in the affected limb and visible changes in the color of the fingers (white to blue to pink) when he's smoking, exposed to cold, or under stress. If the patient is male, ask him if he experiences impotence.
Ask the patient how far he can walk before pain occurs and how long he must rest before it subsides. Can he walk less far now than before, or does he need to rest longer? Does the pain-rest pattern vary? Has this symptom affected his lifestyle?
Review the patient's medical history for risk factors of atherosclerosis, such as smoking, diabetes, hypertension, and hyperlipidemia.
Ask the patient about associated signs and symptoms, such as paresthesia in the affected limb and visible changes in the color of the fingers (white to blue to pink) when he's smoking, exposed to cold, or under stress. If the patient is male, ask him if he experiences impotence.
PHYSICAL
ASSESSMENT:
Palpate for femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Note character, amplitude, and bilateral equality.
Listen for bruits over the major arteries. Note color and temperature differences between the legs or compared with the arms; also note the leg level where changes in temperature and color occur.
Elevate the affected leg for 2 minutes; if it becomes pale or white, blood flow is severely decreased. When the leg hangs down, how long does it take for color to return? (Thirty seconds or longer indicates severe disease.)
Check the patient's deep tendon reflexes after exercise; note if they're diminished in his lower extremities.
Examine the feet, toes, and fingers for ulceration, and inspect the hands and lower legs for small, tender nodules and erythema along blood vessels.
If the patient has arm pain, inspect the arms for a change in color (to white) on elevation. Palpate for changes in temperature, for muscle wasting, and for a pulsating mass in the subclavian area. Palpate and compare the radial, ulnar, brachial, axillary, and subclavian pulses to identify obstructed areas.
Palpate for femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Note character, amplitude, and bilateral equality.
Listen for bruits over the major arteries. Note color and temperature differences between the legs or compared with the arms; also note the leg level where changes in temperature and color occur.
Elevate the affected leg for 2 minutes; if it becomes pale or white, blood flow is severely decreased. When the leg hangs down, how long does it take for color to return? (Thirty seconds or longer indicates severe disease.)
Check the patient's deep tendon reflexes after exercise; note if they're diminished in his lower extremities.
Examine the feet, toes, and fingers for ulceration, and inspect the hands and lower legs for small, tender nodules and erythema along blood vessels.
If the patient has arm pain, inspect the arms for a change in color (to white) on elevation. Palpate for changes in temperature, for muscle wasting, and for a pulsating mass in the subclavian area. Palpate and compare the radial, ulnar, brachial, axillary, and subclavian pulses to identify obstructed areas.
SPECIAL
CONSIDERATIONS:
Nocturnal leg pain is common in older adults. It may indicate ischemic rest pain or restless leg syndrome.
Nocturnal leg pain is common in older adults. It may indicate ischemic rest pain or restless leg syndrome.
PEDIATRIC
POINTERS:
Intermittent claudication rarely occurs in children. Although it sometimes develops in patients with coarctation of the aorta, extensive compensatory collateral circulation typically prevents manifestation of this sign.
Muscle cramps from exercise and growing pains may be mistaken for intermittent claudication in children.
Intermittent claudication rarely occurs in children. Although it sometimes develops in patients with coarctation of the aorta, extensive compensatory collateral circulation typically prevents manifestation of this sign.
Muscle cramps from exercise and growing pains may be mistaken for intermittent claudication in children.
PATIENT
COUNSELING:
Encourage the patient to exercise to improve collateral circulation and increase venous return. Advise him to avoid prolonged sitting or standing as well as crossing his legs at the knees.
Counsel the patient with intermittent claudication about risk factors. Encourage him to stop smoking, and refer him to a support group, if appropriate. Teach him to inspect his legs and feet for ulcers; to keep his extremities warm, clean, and dry; and to avoid injury.
Encourage the patient to exercise to improve collateral circulation and increase venous return. Advise him to avoid prolonged sitting or standing as well as crossing his legs at the knees.
Counsel the patient with intermittent claudication about risk factors. Encourage him to stop smoking, and refer him to a support group, if appropriate. Teach him to inspect his legs and feet for ulcers; to keep his extremities warm, clean, and dry; and to avoid injury.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)