CC: Right lower leg pain

CC: Right lower leg pain
HPI: TY is an obese 64-year-old man complains of cramps in his right calf for the past
month. TY is a postal worker and has noticed that the pain comes on consistently after
walking 2 blocks on flat land. The onset of pain is even sooner when walking fast or
walking up an incline. When he stops and rests for 10 minutes, the pain resolves. He
denied rest pain or symptoms of necrotic tissue. TY has noticed that he can walk shorter
and shorter distances over the last year before his calf cramps. The pain is now severely
interfering with his work and so he has come to see a doctor.
PMH: TY is obese and has a history of diabetes, hypertension, and hypercholesterolemia.
FH: Family history of atherosclerotic disease and multiple myocardial infarctions.
SH: TY has smoked 1 pack per day for 50 years and drinks alcohol socially. He does not
exercise. He lives with his wife, with whom he has had 3 sons.
Physical Exam:
VS: Temp 98.8, Pulse 88, Resp 18, BP 145/85, O2Sa 99% on room air, ht 5’10’’, wt 264
HEENT: PERRLA (pupils equal, round, and reactive to light and accommodation),
EOMI (extraoccular muscles intact), moist mucous membranes, non-tender maxillary
and frontal sinuses
Neck: No lymphadenopathy, no JVD (jugular venous distention), no thyromegaly,
bilateral carotid artery bruits
Pulmonary: CTA-B (clear to auscultation bilaterally)
Coronary: RRR (regular rhythm and rate), normal S1/S2, no rubs/murmurs/gallops.
Abdomen: Soft, non-tender, non-distended, obese, +BS (bowel sounds), no
hepatosplenomegaly, bilateral renal artery bruits
Rectal: No lesions, no fissures, stool brown and firm, normal prostate exam, heme occult
Extremities: Strong right femoral pulse, non-palpable right popliteal and right pedal
pulses, left pulses normal, bilateral lower extremities with shiny, hairless skin, without
ulcerations or gangrene, ankle-brachial index (ABI) of 0.5 (ratio of systolic blood
pressures; normal = 1.0-1.1) in the right lower extremity, right foot is cooler to touch than
left, dependent rubor on right side with marked blanching
Neuro: A&Ox3 (alert and oriented x 3), Cranial Nerves II-XII intact, 4/5 strength lower
extremities (hip flexion/extension, knee flexion/extension, ankle flexion/extension),
normal gait
Lab Data: Chem 7 and CBC is normal