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Posted March 14, 2025CHANGE IN COLOR OF TOES COULD BE SERIOUS!
Case Study: A 62-Year-Old Male with Asymptomatic Peripheral Arterial Disease, Prediabetes, and Benign Prostatic Hyperplasia
Introduction
Routine annual checkups are crucial for identifying asymptomatic or subclinical conditions before complications arise. This case examines a 62-year-old male, Mr. Ntim, who presented for a wellness visit with no complaints but was found to have bilateral toe discoloration, absent pedal pulses, prediabetes, and an elevated prostate volume.
The asymptomatic nature of his peripheral arterial disease (PAD) highlights the insidious progression of atherosclerosis and the value of proactive vascular screening. Prediabetes and obesity provide a window for lifestyle interventions to prevent type 2 diabetes and cardiovascular disease. The case emphasizes a holistic approach to patient care, integrating early detection, risk stratification, and multidisciplinary management.
Chief Complaint
Annual checkup with incidental findings of bilateral toe discoloration and absent pedal pulses.
History of Present Illness
Mr. Ntim reports no acute complaints and recently attended his daughter’s wedding without difficulty. He denies claudication, leg pain, fatigue, chest pain, dizziness, or headaches. Review of systems is otherwise negative.
Key Observations:
Bilateral darkening of toes noted on examination; patient unaware
No prior diagnosis of PAD or diabetes
Past Medical History
Risk Factors: Obesity (BMI 31.93), prediabetes (HbA1c 5.87%)
Medications: None
Allergies: NKDA
Social History: Non-smoker, moderate alcohol use
Physical Examination
Vitals: BP 135/63 mmHg, Pulse 40 bpm (asymptomatic bradycardia), Temp 36°C, Resp 14/min
Cardiovascular:
Pulses: Absent dorsalis pedis (bilateral), diminished popliteal, strong femoral
Extremities: Bilateral toe discoloration, no edema, normal capillary refill
Neurological: Normal cranial nerves, motor strength, and coordination
Other Systems: Clear lungs, non-tender abdomen, no lymphadenopathy
Diagnostic Studies
Test Result
HbA1c 5.87% (prediabetes)
Lipid Profile Total cholesterol 2.84 mmol/L (low)
Renal Function Urea 4 mmol/L, Creatinine 82 µmol/L (normal)
PSA 3.83 ng/mL (normal for age)
Prostate Volume 66 cm³ (BPH)
TSH 1.03 mIU/L (normal)
Assessment/Differential Diagnoses
Peripheral Arterial Disease (PAD): Absent dorsalis pedis pulses, diminished popliteal pulses, toe discoloration. Risk factors: obesity, prediabetes
Prediabetes: HbA1c 5.87%
Benign Prostatic Hyperplasia (BPH): Prostate volume 66 cm³
Bradycardia: Asymptomatic; ECG evaluation recommended
Management Plan
Vascular Workup: Ankle-Brachial Index (ABI), Doppler ultrasound, referral to vascular surgery if critical ischemia
Prediabetes: Lifestyle modifications (weight loss, diet, exercise), monitor HbA1c
BPH: IPSS symptom assessment, urology referral if symptomatic
Bradycardia: ECG to rule out conduction abnormalities
Preventive Care: Foot care education, statin therapy if LDL elevated
Follow-Up
Repeat vascular studies and HbA1c in 3 months
Schedule urology evaluation for BPH
Educate patient on PAD warning signs (e.g., limb pain, coldness)
Discussion
This case illustrates the importance of comprehensive physical exams in asymptomatic individuals. Subclinical PAD, evidenced by absent pedal pulses and toe discoloration, reflects systemic atherosclerosis. Aggressive management of obesity and prediabetes is essential to prevent cardiovascular complications. Early BPH evaluation can reduce urinary morbidity.
Conclusion
This case underscores the importance of proactive screening in detecting subclinical conditions. The patient’s asymptomatic PAD, prediabetes, and BPH highlight age- and metabolic-related health risks. A multidisciplinary approach—including vascular care, urology, and lifestyle interventions—is essential. Long-term follow-up with vascular imaging and glycemic monitoring is recommended to mitigate morbidity.
Final Takeaway
Even in the absence of symptoms, thorough physical examination and targeted diagnostics can reveal critical pathologies, enabling timely interventions that bridge prevention and management of chronic disease.
Keywords: Peripheral Arterial Disease, Prediabetes, Benign Prostatic Hyperplasia, Bradycardia, Preventive Care
Prepared by: Dr. Abunyewa M.D M.B CH.B MSC MIS MACP | Date: 14th March 2025