Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor seeing patients in General Practice. Your next patient is Lance Done, a 61-year-old man with leg pain. Please take a history and perform a relevant examination.
Patient History:
Lance Done, 61 y/o M, retired engineer.
About 7 months ago, you started having pain in both legs that seemed triggered by walking. The pain feels like a cramp and most intensely in your calves and thighs.
You love going on long walks with your wife on a route that winds through a hilly forest. Because of the pain, however, you are forced to take a rest break every 100 metres, and this is getting worse. The pain is not worse or better when walking up or down a hill.
If you are specifically asked, share that you have been having trouble ‘getting it up’ in the bedroom.
You have not noticed any back pain, joint pains, or stiffness in your legs or locking or giving way of your knee joints.
Ideas, Concerns, Expectations:
You think that the pain could be a normal part of the ageing process, but it bothers you that it has been having such a big impact on supposedly the most enjoyable part of your day - spending time with your wife on nice walks. The pain also makes you feel like a burden when your son or grandkids join you on your walk. You would like a treatment plan that works as quickly as possible and do not mind if it involves taking medication.
Past Medical History:
Hypertension, 2 previous myocardial infarctions – 2 and 5 years previously, benign prostatic hyperplasia
Drug History:
Low-dose daily clopidogrel, Propranolol, Atorvastatin, amlodipine, ramipril, indapamide, tamsulosin (No known drug allergies)
Family History:
Sister had a leg clot when she was pregnant.
Social History:
Smoker – 40 cigarettes a day for 30 years.
You drink an occasional pint of beer on the weekend.
No recreational drug use.
You live with your wife at home.
You used to do most of the cooking and cleaning but have lately handed over your household responsibilities to your wife because of your poor health.
You can just about manage the stairs in your home, but you wish you could move into a single-storey flat as it would make your life more convenient.
Examination Findings:
An examination of the peripheral vasculature is most appropriate.
The patient exhibits a large body habitus.
There is an absence of hair on the lower legs.
Both legs look pale and feel cold on palpation.
Capillary refill times are less than 2 seconds bilaterally.
The right dorsalis pedis pulse is present on palpation.
The left dorsalis pedis and both posterior tibial pulses are absent on palpation.
Buerger’s test is positive bilaterally.
Differentials:
Peripheral vascular disease
Spinal canal stenosis
Musculoskeletal causes
Nerve root pain
To rule out DVT
The history and examination above are a classic presentation of intermittent claudication of peripheral arterial disease. Patients with peripheral arterial disease can experience calf pain that is exacerbated by walking and relieved by rest. Typical progression will see the distance a patient can walk without resting (aka the 'claudication distance') decrease over time until the rest pain of critical limb ischaemia is reached.
Additionally, Mr Done is exhibiting signs of aortoiliac involvement: erectile dysfunction and pain in his thighs.
Another key differential of bilateral calf pain exacerbated by walking is the 'neurogenic claudication' caused by spinal canal stenosis. This typically presents as a bilateral posterior leg pain that is relieved by spine flexion.
Investigations:
Bedside:
Blood pressure (hypertension is a modifiable cardiovascular risk factor)
Scoring systems: Rutherford Classification, Fontaine Classification
Doppler US (can confirm the presence or absence of foot pulses when the pulse cannot be felt on palpation)
Ankle brachial pressure index:
A value of 0.5-0.9 is indicative of peripheral arterial disease.
Values of <0.5 indicate critical limb ischaemia.
A normal ABPI does not rule out peripheral arterial disease.
Diabetic or calcified vessels may record ABPI values higher than 0.9 even if peripheral arterial disease is present.
Bloods:
HbA1c and blood glucose
Lipid profile
Coagulation Screen
FBC
Imaging:
Duplex ultrasound is conducted before any revascularisation procedure
CT/MR angiography
Management: