Cardiovascular · Moderate
This case is fictional and exists for study. It describes no real patient.
64 years · male
A 64-year-old male presents to the general practice clinic with a 4-month history of right calf pain that occurs consistently after walking approximately 150 meters. The pain is described as a cramp-like ache that forces him to stop walking, and it completely resolves within 5 minutes of rest. He has a 30-pack-year smoking history and long-standing type 2 diabetes mellitus. He denies rest pain in his feet, toe discoloration, or skin breakdown. On examination, the right lower extremity feels cool relative to the left. Popliteal and dorsalis pedis pulses are weak on the right side. Capillary refill time is 4 seconds on the right big toe.
Vital signs
- HR
- 74 bpm
- BP
- 138/84 mmHg
- RR
- 16/min
- Temp
- 36.7 °C
- SpO₂
- 98%
Examination findings
- Diminished right popliteal and dorsalis pedis pulses
- Cool right lower extremity compared to left
- Capillary refill time 4 seconds on right big toe
- No lower limb ulcers, gangrene, or rest pain
Investigations
| HbA1c | 62 mmol/mol | reference: < 42 |
| Total Cholesterol | 5.8 mmol/L | reference: < 5.0 |
| Serum Creatinine | 88 µmol/L | reference: 60-110 |
Question 1 of 3
What is the most likely diagnosis?
The patient's presentation of exertional, cramp-like calf pain that is reproducibly relieved by rest, combined with diminished peripheral pulses and cool skin, is classic for intermittent claudication due to peripheral arterial disease. Deep vein thrombosis presents acutely with unilateral leg swelling and pain at rest. Critical limb ischaemia is characterized by ischaemic rest pain lasting more than 2 weeks, ulceration, or gangrene. Lumbar spinal stenosis causes neurogenic claudication, which is exacerbated by standing upright/back extension and relieved by spinal flexion (e.g., leaning forward), rather than being strictly dependent on exertion distance.
Teaching point: Intermittent claudication presents with reproducible, exertional lower extremity muscle pain relieved by rest.
Question 2 of 3
Which of the following is the most appropriate initial investigation to confirm the diagnosis?
Ankle-brachial pressure index (ABPI) is the first-line non-invasive diagnostic test to confirm the presence and assess the severity of peripheral arterial disease (ABPI < 0.9 is diagnostic). Duplex ultrasound, CT angiography, and MRA are anatomical imaging modalities used later if revascularization (angioplasty or surgical bypass) is being planned or if diagnosis remains uncertain.
Teaching point: Ankle-brachial pressure index (ABPI) is the first-line investigation for confirming peripheral arterial disease.
Question 3 of 3
Following diagnostic confirmation, which of the following is the most appropriate initial management strategy?
First-line management of stable intermittent claudication includes conservative measures: participation in a supervised exercise program, antiplatelet therapy (e.g., clopidogrel), statin therapy, smoking cessation, and optimization of diabetes and hypertension control. Invasive revascularization (angioplasty or bypass) is indicated only when conservative therapy fails to control severe, lifestyle-limiting symptoms, or if critical limb ischaemia develops. Systemic anticoagulation is not indicated for stable peripheral arterial disease.
Teaching point: First-line management for stable intermittent claudication comprises a supervised exercise program and aggressive cardiovascular risk factor modification.
Key learning points
- Intermittent claudication is characterized by exertional cramp-like muscle pain relieved by rest, caused by underlying peripheral arterial disease.
- Ankle-brachial pressure index (ABPI) is the mandatory initial non-invasive diagnostic test for suspected lower limb arterial disease.
- First-line management of stable intermittent claudication focuses on supervised exercise therapy, antiplatelet and statin medication, and cardiovascular risk factor optimization.
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