Hypertension Case Summary

CHIEF COMPLAINT:
Leg pain upon exertion
HISTORY OF PRESENT ILLNESS:
Pat Donelson is a 67-year-old female who presented today with complaints of pain in her left lower calf. The pain started about 3-4 months ago as an “aching/cramping” pain that she described as mild in nature. She noticed the pain while walking and with adequate rest the pain subsides. Mrs. Donelson discontinued use of Lipitor because she thought it might be causing her leg pain. She also presented with complaints of recurrent headaches, a morning cough, and loss of hair on her effected leg. Mrs. Donelson has a history of periodic angina and heart palpitations; however, at the present time she is asymptomatic.
PAST MEDICAL HISTORY:
Hypertension, diagnosed “years ago,” poorly
Donelson’s age, history of smoking, hypertension, hyperlipidemia, stable angina, and chief complaint of leg pain upon exertion, peripheral artery disease (PAD) should be considered first in the differential. Importantly, risk factors for PAD include being over the age of 50, smoking, hypertension, hyperlipidemia, diabetes, and a personal history of heart disease; Mrs. Donelson has five of the six risk factors. In addition, physical exam findings including bilateral carotid bruits, a pulsatile abdominal mass, and absent/diminished pulses in the lower extremities are suggestive of atherosclerotic disease. The pathophysiology of atherosclerotic disease depends on initial damage to the endothelium of the vessel; both smoking and hypertension have been demonstrated to have this effect. Additionally, hyperlipidemia contributes to macrophage uptake of oxidized-lipids and the formation lesions. Atherosclerotic lesions are plaques composed of a central lipid core, connective tissue, inflammatory cells, and smooth muscle cells, all covered by a fibrous cap. Atherosclerosis accounts for more than 90% of cases of PAD in the United States, and uncommon vascular syndromes account for the remaining 10% (http://www.clevelandclinicmeded.com/). The popliteal arteries are affected in 80% to 90% of symptomatic PAD patients and the tibial and peroneal arteries in 40% to 50%, which is consistent with Mrs. Donelsons findings upon physical exam. Other pertinent findings to consider are
Donelson is to further evaluate her for a diagnosis of PAD using the ankle-brachial index (ABI). ABI is an accurate measure (ABI less than 0.9 has a sensitivity of 95% and specificity of 100% in detecting PAD) that is noninvasive, inexpensive, and office-based. The first line of treatment for Mrs. Donelson will be aimed at lifestyle changes including smoking cessation, supervised exercise therapy, and weight loss. The patient’s uncontrolled hypertension, which is likely contributing to her PAD, will also need to be addressed. Currently, Mrs. Donelson is taking Hydrochlorothiazide (25mg/day), this dose should be increased initially to 50mg/day and HTN will be reevaluated at next visit. If necessary a second drug will be added, such as lisinopril (ACE inhibitor). Bilateral xanthelasma’s suggest dyslipidemia and warrant obtaining a lipid panel to assess the need for intervention. If needed, Lipitor (10mg/day) will be prescribed. A pulsatile, fixed mass was observed in the abdomen upon physical exam, possibly an abdominal aortic aneurysm. To investigate this finding further, an abdominal ultrasound will be ordered. A chest x-ray will also be ordered to address patient concerns as well as physical exam findings suggesting possible pulmonary congestion. Lastly, the patient reported drinking ‘3-4 beers per night’. We discussed the potential detrimental affects of this on her health and the possibility of her cutting back to one beer a night. An 8 week