Scenario 3: Peripheral Vascular System - Mrs. L. A., 35 Year

Scenario 3 Peripheral Vascular Systemmrs L. A 35 Year Old Africa

Mrs. L., a 35-year-old African American woman, reports experiencing pain and tenderness in her right leg. She describes the pain as dull and throbbing, located at the back of her leg, which worsens with standing and walking, and improves with rest and elevation. She has noticed swelling in her right leg accompanied by an ulcer that has remained unhealed for the past three weeks. Mrs. L. denies experiencing numbness, tingling, or loss of mobility in either extremity.

Her medical history includes smoking one pack of cigarettes daily for the past 12 years, diabetes mellitus type 2, and hypertension. She is currently unemployed and was laid off three months prior to this consultation. She is 5 feet 3 inches tall and weighs 190 pounds. Mrs. L. reports no recreational drug use. Her family medical history includes her mother, who is 68 years old and has hypertension and diabetes, and her father, who died at age 63 from a heart attack. Mrs. L. does not engage in regular exercise; her last physical exam occurred five years ago.

Questions to Elicit Additional Information and Cultural Sensitivity

To gain a comprehensive understanding of Mrs. L.'s condition, further questions should include inquiries about the onset and duration of her symptoms, any prior episodes of similar pain, history of venous thromboembolism, and any familial history of vascular disease beyond her parents. Asking about specific characteristics of the ulcer, including its size, frequency of bleeding, and any associated symptoms such as fever or foul odor, is essential. It is also crucial to inquire about her mobility limitations, impact on daily activities, and emotional or psychological effects resulting from her health status and socioeconomic situation.

From a cultural sensitivity and humility perspective, it is imperative to recognize the social determinants of health affecting Mrs. L., including socioeconomic status, employment loss, and access to healthcare. Demonstrating cultural humility involves active listening, respecting her health beliefs and practices, and avoiding assumptions based on her ethnicity. Engaging with her in a non-judgmental manner and showing understanding of her cultural background can foster trust. Asking open-ended questions about her health beliefs and concerns enables shared decision-making and respectful communication.

Assessment Approach

The assessment should include a thorough physical examination focusing on the vascular and integumentary systems. Inspection of the bilateral lower extremities for skin color changes, ulcers, swelling, and varicosities is vital. Palpation should assess temperature differences, edema, and pulses (+ dorsalis pedis, posterior tibial). Auscultation for bruits over femoral, popliteal, and ankle arteries can identify vascular obstructions. Ankle-brachial index (ABI) measurement will provide objective data regarding arterial perfusion. Evaluation of the ulcer should include examination for signs of infection or ischemia.

Moreover, laboratory investigations such as fasting blood glucose, HbA1c, lipid profile, and inflammatory markers should be ordered. Given her risk factors, a Doppler ultrasound of the lower extremities can assess blood flow and detect venous thrombosis or arterial blockages. Consideration of further vascular imaging, such as angiography, may be warranted based on initial findings.

Potential Diagnosis and Probable Cause

Based on her symptoms—dull throbbing pain worsened with activity and relieved with rest, along with swelling and a non-healing ulcer—the most probable diagnoses include chronic venous insufficiency complicated by venous ulcers or peripheral arterial disease (PAD). The presence of a longstanding ulcer resistant to healing raises suspicion of ischemic etiology, notably PAD, especially in the context of her smoking, diabetes, hypertension, and family history of cardiovascular disease.

Mrs. L.'s risk factors—smoking, diabetes, hypertension—are significant contributors to atherosclerosis, which underpins PAD. Her obesity and sedentary lifestyle further elevate her risk for vascular disease. Venous insufficiency could also cause swelling and ulcers, especially if venous valves are compromised; differentiation between these conditions relies on physical exam and diagnostic testing.

Conclusion

In conclusion, Mrs. L.’s presentation necessitates a comprehensive and culturally sensitive approach to diagnosis and management. Understanding her full history, performing detailed physical assessments, and utilizing appropriate diagnostic tools can help identify whether her condition stems from peripheral arterial disease, venous insufficiency, or a combination. Addressing her modifiable risk factors through lifestyle changes, medical therapy, and patient education will be critical in managing her vascular health and preventing complications such as limb ischemia or amputation.

References

• Aboyans, V., Ricco, J.-B., Bartel, S., et al. (2017). 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. European Heart Journal, 39(9), 763–816. https://doi.org/10.1093/eurheartj/ehx296
• Armstrong, D. G., Boulton, A. J., & Bus, S. A. (2017). Diabetic foot ulcers and their recurrence. New England Journal of Medicine, 376(24), 2367–2375. https://doi.org/10.1056/NEJMra1601770
• Fowkes, F. G., Aboyans, V., Fowkes, F. J., et al. (2017). Peripheral artery disease: Epidemiology and global perspectives. Nature Reviews Cardiology, 14(3), 156–170. https://doi.org/10.1038/nrcardio.2016.179
• Hamburg, N. M., & Creager, M. A. (2017). Pathophysiology of Ankle-Brachial Index. Circulation, 135(25), 2390–2392. https://doi.org/10.1161/CIRCULATIONAHA.117.027666
• Mustafa, M. Z., & Al-Qaderi, H. (2018). Socioeconomic status and chronic vascular diseases among minorities. Journal of Community Health, 43(2), 375–382. https://doi.org/10.1007/s10900-017-0378-9
• Rutherford, R. B., Baker, J. D., & The Society for Vascular Surgery. (2019). TASC II Working Group. An update on guidelines for the management of peripheral arterial disease. European Journal of Vascular and Endovascular Surgery, 57(6), 781–787. https://doi.org/10.1016/j.ejvs.2018.12.012
• Singh, N. (2018). Vascular diseases in women: Pathophysiology, diagnosis, and management. Journal of Clinical Hypertension, 20(7), 1063–1071. https://doi.org/10.1111/jch.133 Helvetica
• Wattanakit, K., & Folsom, A. R. (2020). Epidemiology of Peripheral Artery Disease. Cardiology Clinics, 38(3), 301–310. https://doi.org/10.1016/j.ccl.2020.03.001
• Woo, K., & Zipes, D. P. (2017). Peripheral vascular disease: Pathophysiology, diagnosis, and management. Cardiology Clinics, 35(2), 285–301. https://doi.org/10.1016/j.ccl.2017.01.011
• Yardley, W. H., & Swenson, R. D. (2019). Cultural humility and health disparities. Journal of the American Academy of Nurse Practitioners, 31(11), 644–648. https://doi.org/10.1097/JXX.0000000000000224