Case Study: A 62-Year-Old Male with Asymptomatic Peripheral Arterial Disease, Prediabetes, and Benign Prostatic Hyperplasia

Introduction

Routine annual checkups play a critical role in identifying asymptomatic or subclinical conditions that may otherwise go undetected until complications arise. This case study examines a 62-year-old male, Mr. Ntim, who presented for a general wellness visit with no overt complaints but exhibited significant findings, including bilateral toe discoloration , absent pedal pulses , and prediabetes . These findings, coupled with an elevated prostate volume, highlight the complex interplay between vascular health, metabolic risk factors, and age-related benign prostatic hyperplasia (BPH). The absence of symptoms in peripheral arterial disease (PAD)—despite marked physical and diagnostic abnormalities—underscores the insidious nature of atherosclerosis and the importance of proactive vascular screening in high-risk populations. Similarly, prediabetes and obesity signal a window of opportunity for lifestyle interventions to prevent progression to type 2 diabetes and cardiovascular disease. This case emphasizes the need for a holistic approach to patient care, integrating early detection, risk stratification, and multidisciplinary management to mitigate long-term morbidity. By exploring the diagnostic and therapeutic strategies employed, this study aims to reinforce the value of comprehensive physical exams and lab testing in guiding preventive care, even in seemingly "healthy" asymptomatic individuals.

Chief Complaint

Annual checkup with incidental findings of bilateral toe discoloration and absent pedal pulses.

History of Present Illness

The patient is a 62-year-old male, presents for a routine annual examination. He reports no acute complaints and recently attended his daughter’s wedding without difficulty. He denies claudication, leg pain, fatigue, or systemic symptoms (e.g., chest pain, dizziness, headaches). Review of systems is otherwise negative.

• Key Observations:
  • Bilateral darkening of toes noted by clinician; patient unaware of the change.
  • No prior diagnosis of peripheral arterial disease (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 (bilaterally, non-Dopplerable), diminished popliteal, strong femoral.
  • Extremities: Bilateral toe discoloration (dark hue), 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 (benign prostatic hyperplasia)
TSH	1.03 mIU/L (normal)

Assessment/Differential Diagnoses

1. Peripheral Arterial Disease (PAD): Absent dorsalis pedis pulses, diminished popliteal pulses, and toe discoloration. Risk factors: Obesity, prediabetes.
2. Prediabetes: HbA1c 5.87% (elevated).
3. Benign Prostatic Hyperplasia (BPH): Prostate volume 66 cm³ (normal <30 cm³).
4. Bradycardia: Asymptomatic; requires ECG evaluation.

Management Plan

• Vascular Workup: Ankle-Brachial Index (ABI), Doppler ultrasound, vascular surgery referral if critical ischemia.
• Prediabetes: Lifestyle modifications (weight loss, diet, exercise), HbA1c monitoring.
• 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.
• Patient education on PAD warning signs (e.g., limb pain, coldness).

Discussion

This case highlights the importance of thorough physical exams in asymptomatic patients. Subclinical PAD, marked by absent pedal pulses and toe discoloration, signals systemic atherosclerosis. Aggressive management of obesity and prediabetes is critical to prevent cardiovascular complications. Early BPH intervention may reduce urinary morbidity.

Conclusion

This case study underscores the critical role of proactive screening and comprehensive clinical evaluation in identifying subclinical conditions during routine care. The patients asymptomatic presentation of **peripheral arterial disease (PAD)**—evidenced by absent pedal pulses and toe discoloration—highlights the silent progression of atherosclerosis and the necessity of vascular assessments in at-risk populations (e.g., obesity, prediabetes). His **prediabetes** (HbA1c 5.87%) and **benign prostatic hyperplasia (BPH)** further illustrate the cumulative burden of age-related and metabolic conditions, emphasizing the need for early intervention to prevent diabetes, cardiovascular events, and urinary complications. The management plan, centered on **multidisciplinary care** (vascular surgery, urology, and lifestyle modification), reflects a holistic approach to addressing interconnected health risks. Long-term follow-up, including vascular imaging and glycemic monitoring, will be essential to mitigate morbidity. This case reinforces that asymptomatic findings in otherwise healthy-appearing individuals warrant thorough investigation and tailored preventive strategies to improve patient outcomes.

Disclaimer & Credit: All medical articles including ours, are informative and provide population trends not specific to individuals which can be very different. Always seek personalized medical advice from your doctor for individual healthcare decisions.

Posted March 14, 2025