Comprehensive Patient Assessment Guide for PAD Management

Patient History

This section should detail the patient history including: subjective information, medical history, exercise history, medications, reported symptoms and exacerbating factors

Assessment Selection/Expected Outcomes

List all assessments that you would complete to both screen for safety and assess the exercise responses/capacities of the client. This is not limited to tests covered leading up to this assessment in the unit, so please do some research. Justify your selections in relation to the case study.

Write a brief statement for each of the selected assessments, estimating and describing what you may expect the results to look like given what you know about this specific case and their conditions. Again, researching the conditions, comorbidities, etc. is essential to doing this well. These statements should include a succinct justification for why you would expect these outcomes.

Assessment 2 SCL6000

Patient History

Bob is a 58 year old man who has recently been diagnosed with Peripheral Arterial Disease(PAD). His past medical history includes:

• Chronic Obstructive Pulmonary Disease (COPD)

• Type 2 Diabetes (T2DB) and

• Hypertension (HTN)

These are managed with several medications:

• Salbutamol (Ventolin) Bronchodilator for COPD

• Metformin Biguanide for T2DB,

• Atenolol Beta-Blocker for HTN

• Aspirin Non-steroidal Anti-inflammatory Drug (NSAID) for pain

Previously, patients physical activity was at a good standard (2-3 times a week for ~30minutes). Now he struggles to walk more than 5-10 minutes without stopping for a break, during which he experiences mild to moderate pain in his left leg after a few minutes of walking. He used to belong
to a gym (during his 20-30s) but has not had a membership in the last 5+ years.

He has a weight of 140kg (has gained 25kg in the past year), height of 184cm and therefore a BMI of 41.4 (Obese). There is no family history of cardiovascular disease (CVD) and both his parents are still alive. Bob smokes a pack of cigarettes a day, consumes alcohol most nights of the week (2-3 beers a night) and admits to ordering takeaway frequently. He used to belong to a gym (during his 20-30s) but has not had a membership in the last 5+ years.

Bobs last blood test results show elevated levels of Low-Density Lipoprotein Cholesterol (LDL-C) (3.70 mmol/L) and Fasting Plasma Glucose (8.0 mmol/L); both of these results are outside normal ranges (1). However, his High-Density Lipoprotein Cholesterol (HDL-C) is at an appropriate level (1.8
mmol/L).

With HTN medication, he shows an elevated BP of 138/84 mmHg (Systolic/Diastolic). He has an Ankle Brachial Index (ABI) of 0.60 in his left leg.

Assessment Selection/Expected Outcomes

Before any assessments are conducted, a full Adult Pre-exercise Screening System (APSS) will be performed. The screening tool used will be provided by Exercise and Sport Science Australia (ESSA). This will include a doctors referral if needed.

Spirometry testing

As the patient has been diagnosed with COPD, a spirometry test will be conducted to screen for lung function and for safety in future tests. It is expected to see a concave flow-volume loop shape (Figure 1) as obstruction is present (2). 2-3 spirometry trials will be completed depending on patients cough severity. Results show a severely hindered FEV1, low FVC and low FEV1/FVC ratio. Patient will be evaluated with a dose of Salbutamol before each trial.

Results:

FEV1 (L): 0.56

FVC (L): 1.98

FEV1/FVC (%): 28%

Figure 1 Patients Expected Flow/Volume Loop (3)

Graded Exercise Test (GXT)

The patient will complete a GXT using the Bruce Protocol. The following measurements will be examined after every stage:

- Heart Rate (HR) using a Pulse Oximeter;

- Rated Perceived Exertion (RPE) using the Borg RPE scale and

- Blood Pressure (BP) using a BP cuff and stethoscope

A Claudication Pain Scale (CPS) will be used (1 equivalent to no pain, 5 equivalent to severe pain) to find the first occurrence of pain, done periodically through the test, and at peak exercise (4). As patients with PAD are at a higher risk of a cardiovascular event (5), an electrocardiogram (ECG) and a
pulse oximeter measuring oxygen saturation levels (%SpO2) will be used to monitor the patients safety while conducting the assessment. During GXT, Bobs cough and balance during gait will be monitored.

Table 1: Expected Last Stage GXT Results

Time to onset of claudication pain: 240s

Time to maximal claudication pain: 480s

Test was ended when patient was unable to continue due to pain.

1RM strength test

Patient will undertake a 1RM strength test on a Leg Press Machine (LP1RM) and Chest Press machine (CP1RM), testing lower body and upper body strength. Machine loaded exercises are chosen due to patients exercise history with safety in mind. Patients with PAD often present with lower body muscle atrophy and muscle weakness (6). To improve walking ability, a lower body strength program is advisable (7). LP1RM and CP1RM results consider body weight of the patient, co-morbidities as well as normative data of males in a similar age range (8). To reduce the effects of the Valsalva Manoeuvre, proper breathing technique will be demonstrated and monitored for safety. Proper lifting technique will also be demonstrated and monitored.

Expected Results:

LP1RM: 180kg

CP1RM: 80kg

Mental Health Questionnaire

Use of the Patient Health Questionnaire 8 (PHQ-8). Mental health concerns are prevalent in patients with symptomatic PAD (9). Thus, the PHQ-8 will be used to manage the patients mental health and be used as a measure of depression (10). The questionnaire will assist with patients goal
setting, mindset going from session to session and emphasis on holistic health. A result of ?10 denotes prevalence of depression.

Expected Result: 10

Timed up and go (TUG)

The TUG will be used to evaluate overall functional mobility (11) and manage falls risk. Patient will perform the test 4 times total; 2 times turning to the left, 2 times turning to the right. This will uncover differences in balance while turning from the left and right leg. Median results for males in
the 50 y/o category are 9.9 seconds (11).

Expected time: 11.2 seconds

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