Right Calf Pain with Walking

Abstract

A 65-year-old male presents with a 5-month history of progressively worsening right calf pain upon walking. He describes the pain as a tightening or cramping, and it comes on after walking two blocks. The pain forces him to stop walking and is relieved after he sits down for 5 minutes. The pain comes on consistently at the same two-block walking distance each time, unless he walks fast or uphill, in which case he can walk much less. He denies waking up at night with pain in his foot. He reports a 40-pack-year smoking history and is taking antihypertensives. He has normal 2+ femoral pulses bilaterally; nonpalpable (0) popliteal, dorsalis pedis, and posterior tibial pulses on the right side; and diminished (1+) popliteal, dorsalis pedis, and posterior tibial pulses on the left. He is moderately obese, yet both legs appear to be thin. The skin on his lower legs appears thin and shiny, flaky, and dry, with no hair. His toenails are thickened. There are no ulcers in his feet. Capillary refill is diminished in his right foot at 4 seconds (normal ≤ 2 seconds). Laboratory values reveal a total cholesterol of 280 mg/dL (normal < 200 mg/dL), low-density lipoprotein (LDL) of 160 mg/dL (65–180 mg/dL), and a high-density lipoprotein (HDL) of 35 mg/dL (>35 mg/dL).