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Key Case Information
In the case under consideration, a 76-year-old patient presents to a healthcare facility with the chief complaint of hard skin on the balls of his feet and a burning sensation. Primary assessment helps to reveal a number of serious social and medical issues that may play a role in further clinical neurovascular evaluation. Among the offered variety of diseases and symptoms, attention has to be paid to the fact that the patient was diagnosed with Type 2 diabetes (that does not require using insulin) eight years ago. The patient faces certain challenges in treating this disease because he does not find it necessary to monitor the level of blood glucose regularly. In addition, he smokes more than 20 cigarettes per day. Individually, this bad habit and diabetes enhance the risks of cerebrovascular and neurological disorders (Prasad & Cucullo, 2015). His past medical history also shows that the patient has osteoarthritis, hypertension, hypercholesterolemia, and myocardial infarction. There are certain changes in foot condition, including the absence of hair on legs, telangiectasia, haemosiderin deposits, and anhidrotic skin. All these problems can be defined as serious diabetes- and hypertension-related complications.
In the list of the above-mentioned signs and complaints, a burning sensation at night and the ankle-brachial pressure index turn out to be the two points that may indicate the neurovascular status. According to Tavee and Zhou (as cited in Volmer-Thole & Lobmann, 2016), diabetic neuropathy of the lower extremities is characterized by a high sensation of pain and the “burning feet syndrome” that usually arises at night. Another important issue is the ankle-brachial index (ABI) or the ankle-brachial pressure index (ABPI) within normal limits (1.3 in the right leg and 1.27 in the left leg). Singer, Tassiopoulos, and Kirsner (2017) state that “falsely normal or even elevated ABIs may be seen in patients with non-compressible vessels, in patients with diabetes that is caused by glycation of blood vessels, and in elderly patients with vessel calcification” (p. 1562). New diagnostic tools are required to clarify the diagnosis and define the neurovascular status.
This diabetic patient with the signs of neurovascular abnormalities has to be properly assessed and diagnosed, taking into consideration all the available information and observations. A clinical neurovascular assessment, as well as a specific neurological assessment, is an integral part of the diagnosis of some orthopedic conditions caused by neurovascular injury to the extremities (Maher, 2016; Rawles, 2014). American Diabetes Association (2016) recommends “inspection of the skin, assessment of foot deformities, neurological assessment including 10-g monofilament testing and pinprick or vibration testing or assessment of ankle reflexes, and vascular assessment including pulses in the legs and feed” (p. 78). There are many standards for patient observations, and the Royal Children’s Hospital Melbourne (2015) indicates one hourly observation for the first 24 hours of application and then four hourly for a further 48 hours. There are six cardinal clinical manifestations, also known as the six Ps. They are pain, poikilothermia, paresthesia, paralysis, pulse, and pallor, and not all of them may be present in every diabetic patient (Pechar & Lyons, 2016). Taking into account this theoretical basis and explanations, the following outline to a clinical neurovascular assessment of the patient may be developed:
- Pain (ask to rate pain from 0 to 10 and share its possible characteristics like burning, sharpness, periodic, etc.);
- Pulse (check the distal pulse and note its characteristic like strong, weak, or absent);
- Pallor (observe the color of the skin and check capillary refill);
- Poikilothermia (evaluate temperature);
- Paresthesia (analyze sensation by paying attention to the patient’s response to physical stimulation);
- Paralysis (ask the patient to take several actions).
Reliability and Limitations of ABIs
The ABPI is usually a part of the neurovascular assessment that has to be performed regularly to observe changes and report on them as soon as possible. This test helps to approve the results of palpation of arterial pulses in the foot. A standard pressure cuff and a Doppler ultrasound tool are used to measure pressure (Singer et al., 2017). This non-invasive procedure is based on the production of sound waves, which is not harmful to a patient. These simple means are reliable for diagnosing peripheral arterial disease (PAD). If an ABI is lower than 0.8, vascular abnormalities due to arterial insufficiency may be observed in a patient (Singer et al., 2017). However, underestimation of the severity of health problems can be possible due to the ABI tests because of the elevation of the results due to diabetes-related changes (Amin & Doupis, 2016). Therefore, there is a lack of standardization of the chosen test that can be defined as its major limitation. Vascular surgeons choose computer tomography (CT) or magnetic resonance angiography (MRA) to continue assessment and make a final diagnosis.
Doctors recommend this test to be regularly taken by the patients who experience pain in the leg or foot, as well as those with risk factors for PAD (tobacco smokers, diabetic, hypertonic, or atherosclerotic patients). In addition, old age is another factor that may influence the results of the ABPI test. In this case, the patient is an old-aged diabetic man with signs of PAD that get worse at night. The ABPI test will hardly be enough to identify his status and develop a treatment plan.
Interpretation of Results and Recommendations
The presenting case information can be used to make several evidence-based predictions about the results of this clinical neurovascular assessment. For example, PAD is diagnosed on the basis of such symptoms as coldness in the foot, a burning sensation (especially at night), hard skin, and the change in the legs’ color (Amin & Doupis, 2016). Other contributors to this condition include the age of the patient, a serious smoking habit, and his diabetes and hypertension history. The presence of such complications as myocardial infarction, osteoarthritis, and lower back pain proves the impact of diabetes on the patient’s overall health.
Further actions to predict the emergence of new problems may vary from patient education, counseling, and lifestyle changes to surgery and post-operative care. It is important to control the blood sugar level all the time to predict diabetic kidney disease (American Diabetes Association, 2016). Glycemic control and keeping a healthy weight are also important interventions for diabetic patients (Amin & Doupis, 2016). Pharmacological treatment is another recommendation to stabilize the condition of the man and relieve pain. Medications like antibiotics (metronidazole or dapsone), vitamin B6, and antiarrhythmic drugs (Amiodarone) can be prescribed to deal with possible peripheral neuropathy complications (Volmer-Thole & Lobmann, 2016). In general, the condition of this 76-year-old male patient is not critical, but much attention has to be paid to his feet and the changes of the ABPI during the next 48 hours.
American Diabetes Association. (2016). Microvascular complications and foot care. Diabetes Care, 39(1), 72-80. Web.
Amin, N., & Doupis, J. (2016). Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities. World Journal of Diabetes, 7(7), 153-164.
Maher, A. B. (2016). Neurological assessment. International Journal of Orthopaedic and Trauma Nursing, 22, 44–53. Web.
Pechar, J., & Lyons, M. M. (2016). Acute compartment syndrome of the lower leg: A review. The Journal for Nurse Practitioners, 12(4), 265-270.
Prasad, S., & Cucullo, L. (2015). Impact of tobacco smoking and type 2-diabetes mellitus on public health: A cerebrovascular perspective. Journal of Pharmacovigilance, 2. Web.
Rawles, Z. (2014). Assessing the foot in patients with diabetes. Nursing Times, 110(31), 20-22.
The Royal Children’s Hospital Melbourne. (2015). Neurovascular observations. Web.
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Singer, A. J., Tassiopoulos, A., & Kirsner, R. S. (2017). Evaluation and management of lower-extremity ulcers. New England Journal of Medicine, 377(16), 1559-1567.
Volmer-Thole, M., & Lobmann, R. (2016). Neuropathy and diabetic foot syndrome. International Journal of Molecular Sciences, 17(6). Web.