CHIEF COMPLAINT: Leg pain upon exertion HISTORY OF PRESENT ILLNESS: Pat Donelson is a 67-year-old female who presented today with complaints of pain in her left lower calf. The pain started about 3-4 months ago as an “aching/cramping” pain that she described as mild in nature. She noticed the pain while walking and with adequate rest the pain subsides. Mrs. Donelson discontinued use of Lipitor because she thought it might be causing her leg pain. She also presented with complaints of recurrent headaches, a morning cough, and loss of hair on her effected leg. Mrs. Donelson has a history of periodic angina and heart palpitations; however, at the present time she is asymptomatic.
PAST MEDICAL HISTORY: Hypertension, diagnosed “years ago,” poorly controlled. Hyperlipidemia, currently not taking any medication Periodic Angina and heart palpitations PAST SURGICAL HISTORY: Tonsillectomy and Hernia surgery as a child FAMILY HISTORY: Mother and father are deceased and Mrs. Donelson is unaware of any medical problems. SOCIAL HISTORY: Married with three grown children, all healthy with no known medical issues. Mrs. Donelson used to work as a plumber but now is an office clerk. She has no pets. She is a smoker (since 22 y/o, 1/day) and drinks 3-4 beers a day after work. MEDICATIONS: Hydrochlorothiazide (25mg/day for 5 years) Aspirin (81mg/day) Nitroglycerine as needed (1-2 times in last year)
ALLERGIES: No known allergies. REVIEW OF SYSTEMS: General: No weight change, fatigue, or trouble sleeping HEENT: Head – recurrent headaches, no dizziness or syncope Ears – no changes and/or difficulty with hearing Eyes – no changes in vision, blurring, spots Nose – not assessed Throat – not assessed Respiratory: Cough in morning, no shortness of breath. CV: History of chest pain and palpitations, currently asymptomatic. Gl: reports regular bowel movements with no change in color and no blood Urinary: no dysuria, increased urination, tingling, or pain Female Genital: not assessed Neurological: not assessed Hematological: denies easy bruising Endocrine: not assessed Psych: no report of depression Extremities: No edema, no numbness. Refer to HPI for additional symptoms
PHYSICAL EXAM FINDINGS: Vital Signs: 5’4″ 165 lbs femal. B/P 162/94, pulse 88, respirations 18, afebrile General: Mrs. Donelson appeared alert, healthy, and comfortable. HEENT: Poor dental hygiene, multiple caries and dental fractures. Plaque-like fatty deposits are seen on both medial upper eyelids (Xanthelasma) Neck: thyroid not palpable, carotid pulses are equal with bruits bilaterally, no JVD Respiratory: Breath sounds are diminished at base; upper airway rhonchi clear with cough Heart: Heat rate/rhythm regular with no murmurs, rubs, or ectopy. Heart sounds normal Abdomen: Obese with recurrent umbilical hernia, pulsatile mass deep in mid abdomen. Pulses: The dorsalis pedis, posterior tibial, and popliteal pulses are absent on left and diminished on right and femoral pulses are normal Extremities: No edema or venous stasis evident, no calf tenderness or sign of trauma.
There is anterolateral alopecia on the left calf. Neurological: Unremarkable Laboratory Data: None collected Diagnostic Tests: None performed ASSESSMENT/PROBLEM LIST 1) Left calf pain upon exertion 2) Absent/diminished pulses in lower extremities 3) Pulsatile, fixed mass deep in mid abdomen 4) Hypertension 5) Hyperlipidemia 6) Breath sounds diminished at base of lungs bilaterally with rhonchi cleared with cough. 7)Smoker 8) Possible alcohol dependence DIFFERENTIAL DIAGNOSIS: 1) Peripheral Artery Disease 2) Spinal Stenosis 3) Deep Vein Thrombosis 4) Arterial Embolism 5) Osteoarthritis 6) Stress Fracture 7) Thromboangitis Obliterans DISCUSSION OF PRMARY DIFFERENTIAL DIAGNOSIS: Given Mrs. Donelson’s age, history of smoking, hypertension, hyperlipidemia, stable angina, and chief complaint of leg pain upon exertion, peripheral artery disease (PAD) should be considered first in the differential.
Importantly, risk factors for PAD include being over the age of 50, smoking, hypertension, hyperlipidemia, diabetes, and a personal history of heart disease; Mrs. Donelson has five of the six risk factors. In addition, physical exam findings including bilateral carotid bruits, a pulsatile abdominal mass, and absent/diminished pulses in the lower extremities are suggestive of atherosclerotic disease. The pathophysiology of atherosclerotic disease depends on initial damage to the endothelium of the vessel; both smoking and hypertension have been demonstrated to have this effect. Additionally, hyperlipidemia contributes to macrophage uptake of oxidized-lipids and the formation lesions.
Atherosclerotic lesions are plaques composed of a central lipid core, connective tissue, inflammatory cells, and smooth muscle cells, all covered by a fibrous cap. Atherosclerosis accounts for more than 90% of cases of PAD in the United States, and uncommon vascular syndromes account for the remaining 10% (http://www.clevelandclinicmeded.com/). The popliteal arteries are affected in 80% to 90% of symptomatic PAD patients and the tibial and peroneal arteries in 40% to 50%, which is consistent with Mrs. Donelsons findings upon physical exam. Other pertinent findings to consider are anterolateral alopecia on the effected leg and pain with exertion that subsides upon rest, both of which are classic presentations in symptomatic PAD. DISCUSSION OF COMPETING DIFFERENTIAL DIAGNOSES: Lumbar spinal stenosis (LSS) classically presents as bilateral neurogenic claudication (NC).
NC is believed to be the results of increased metabolic demand during ambulation and downstream ischemia to nerve roots as a result of stenosis. Significant LSS can result in pain, weakness, numbness in the legs while walking, or a combination of the above. The symptoms are typically relieved when the patient flexes the spine, increasing the canal size and relieving the pressure on the exiting nerve roots. Although it is possible that Mrs. Donelson has LSS, the fact that her pain is unilateral and not bilateral, only upon exertion and not constant, and described as aching/ cramping and not numbness or weakness would suggest another pathology; additionally, her other cardiovascular pathologies and risk factors point towards PAD as the likely diagnosis over LSS.
A diagnosis of deep vein thrombosis (DVT) remains high on the list; however, DVTs typically present with pain, swelling, and tenderness in the effected leg. Mrs. Donelsons symptoms did not include swelling or tenderness and where dependent on exertion, thus making DVT lower on the list of differentials. Although an Arterial embolism is a possibility, the observation that the patient has symptoms upon exertion that are alleviated with rest is suggestive of PAD. The only way to rule out this diagnosis would be to perform an angiograph of the effected leg. Other differentials include pathologies affecting the bone. Osteoarthritis (OA) is characterized by breakdown of the cartilage, bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining. OA tends to affect the more commonly used joints, such as the knee.
Mrs. Donelsons presentation of leg pain upon exertion makes OA a possible differential; however, the location and description of the pain are atypical of OA. Another possible pathology affecting the bone could be a stress fracture, which is often considered an overuse injury. The age and gender of our patient make her more susceptible to this type of injury. This differential is low on the list due to Mrs. Donelsons relatively sedentary lifestyle and can quickly be evaluated with an x-ray. PLAN: The first priority for Mrs. Donelson is to further evaluate her for a diagnosis of PAD using the ankle-brachial index (ABI). ABI is an accurate measure (ABI less than 0.9 has a sensitivity of 95% and specificity of 100% in detecting PAD) that is noninvasive, inexpensive, and office-based.
The first line of treatment for Mrs. Donelson will be aimed at lifestyle changes including smoking cessation, supervised exercise therapy, and weight loss. The patient’s uncontrolled hypertension, which is likely contributing to her PAD, will also need to be addressed. Currently, Mrs. Donelson is taking Hydrochlorothiazide (25mg/ day), this dose should be increased initially to 50mg/day and HTN will be reevaluated at next visit. If necessary a second drug will be added, such as lisinopril (ACE inhibitor). Bilateral xanthelasma’s suggest dyslipidemia and warrant obtaining a lipid panel to assess the need for intervention. If needed, Lipitor (10mg/day) will be prescribed.
A pulsatile, fixed mass was observed in the abdomen upon physical exam, possibly an abdominal aortic aneurysm. To investigate this finding further, an abdominal ultrasound will be ordered. A chest x-ray will also be ordered to address patient concerns as well as physical exam findings suggesting possible pulmonary congestion. Lastly, the patient reported drinking ‘3-4 beers per night. We discussed the potential detrimental affects of this on her health and the possibility of her cutting back to one beer a night. An 8 week follow-up appointment will be scheduled with Mrs. Donelson to check in and see how the new therapies are working.