S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately 2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise and is relieved with rest

Question

Two years ago, S.P. could walk two city blocks before having to stop because of
leg pain. Today, he can barely walk across the yard. S.P. has smoked two to three packs of cigarettes per
day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN),
peripheral artery disease (PAD), and osteoarthritis. Surgical history includes quadruple coronary artery
bypass graft (CABG × 4) 3 years ago. He has had no further symptoms of cardiopulmonary disease since
that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed,
continues to eat anything he wants, and continues to smoke two to three PPD. Other surgical history
includes open reduction internal fixation of a right femoral fracture 20 years ago.
S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care provider.
As you take his vital signs, he tells you that in addition to the calf pain, he is experiencing right hip
pain that gets worse with exercise, the pain doesn't go away promptly with rest, some days are worse
than others, and his condition is not affected by a resting position.

General Assessment
Weight 261 lb
Height 5 ft, 10 in
Blood pressure (BP) 163/91 mm Hg
Pulse 82 beats/min
Respiratory rate 16 beats/min
Temperature 98.4 ° F (36.9 ° C)
Laboratory Testing (Fasting)
Cholesterol 239 mg/dL
Triglycerides 150 mg/dL
HDL 28 mg/dL
LDL 181 mg/dL
Current Medications
Ramipril (Altace) 10 mg/day
Metoprolol (Lopressor) 25 mg twice a day
Aspirin 81 mg/day
Simvastatin (Zocor) 20 mg/day

What are the likely sources of his calf pain and his hip pain?

Answer 1

• Given S.P.'s history, his calf pain is caused by intermittent claudication—a reproducible severe pain
in the calf muscle that occurs during exercise and is relieved during rest. It should be noted that
patients with advanced or severe arterial occlusive disease would experience pain even at rest.
• The history of his hip pain is consistent with osteoarthritis—the pain does not disappear promptly
after exercise, may be associated with changes in the weather, and can vary in intensity.
• Another possible source of hip pain could be pseudoclaudication—this pain is caused by
neurospinal canal compression. The pain is related to posture and is not made worse with exertion
or relieved with rest. Pseudoclaudication causes pain when the body is in an erect position or
leaning forward (leaning over a shopping cart); lying or sitting can relieve the pain.