History of Presenting Complaint

• Site – pain is present bilaterally in the lower legs
• Onset – started around 6-7 months ago
• Character – cramping
• Radiation – none (if asked specifically no shooting pains down the back of the leg)
• Associated symptoms – none. (if asked specifically no back pain)
• Timing – worse when walking. Candidate should explore this further, the patient was initially able to walk for around one hour, but now has to stop every 10 minutes.
• Exacerbating/ Relieving factors – rest makes the pain better. Pain is worse when walking.
• Severity – 6/10

ICE

• Ideas – could this be some sort of muscular pain, or just a part of ‘getting old’
• Concerns – isn’t particularly concerned about the pain, but wants it to be treated
• Expectations – wants some pain-relief so he can walk as well as he used too!

Systems review

• Red flags: no fever, no weight loss, no night sweats
• Cardiovascular: no palpitations, no syncope, no chest pain.
• Respiratory: no shortness of breath, no cough

Past Medical History

• Diabetes – type 2 diabetes, diagnosed 5 years ago
• Hypertension
• If candidate attempts to ask about diabetic or hypertension control, the actor should appear irritated and defensive. If the candidate enquires in a sensitive manner, the patient admits that they aren’t very compliant with their medication, as they feel fine and don’t see the point. Give candidates an opportunity to counsel regarding the importance of diabetic and hypertensive control, and if the candidate is empathetic and understanding agree to think about this further.

Medications

• Metformin
• Lorsartan
• Simvastatin

Allergies

• Ramipril – if candidates ask specifically about the nature of the allergy, the patient explains he had a dry cough

Family History

• Father had a heart attack at the age of 65, older brother has angina

Social History

Smokes 10 cigarettes a day for the last 10 years

Works as an account

Lives at home with his wife, has 2 children and 3 grandchildren

Basic observations

Temperature 37.2, heart rate 60, oxygen saturations 97%, blood pressure 155/98, respiratory rate 14

General Inspection

Comfortable at rest

Hands

Normal CRT, no clubbing, evidence of tar staining

Face

No conjunctival pallor, no cyanosis

Vascular examination

Radial pulses equal

Normal JVP

Temperature of feet and lower legs is cold

Dorsalis pedis, tibialis posterior and the popliteal pulses cannot be palpated

No evidence of skin changes or ulcers in the legs

No evidence of peripheral oedema

Examination of the chest

Inspection – no scars

No heaves or thrills

Heart sounds I + II present, with no added sounds

1. What are your key differential diagnoses?

• Peripheral vascular disease: The patient gives a typical history of intermittent claudication, with cramping pain on exertion that is better with rest. In addition, the patient has multiple cardiac risk factors, such as hypertension, diabetes, and smoking (1).
• The lack of radiation or classical ‘shooting pains’ suggest that nerve compression is less likely, however this is still an important differential to consider.
• Arthritis: This is unlikely based on the history described above.

2. Please discuss your management plan with the patient.

Refer to NICE guidelines (3) and CKS (1) for more detailed guidelines.

Intermittent claudication should be explained to the patient.

The patient should be counselled about optimising diabetes and hypertension control.

Antiplatelet therapy (clopidogrel) should be discussed, with explanation about the importance of preventing future cardiovascular events (2).

Signposting to services to support in smoking cessation.

The importance of lifestyle interventions (diet, exercise) should also be discussed, with discussion about the importance of statins for lowering risk even if there are few symptoms.

Supervised exercise programme

The patient should ask about surgery, as his neighbour had “some sort of procedure to improve the blood supply to his legs”. Candidate should explain that this would only be offered if the supervised exercise programme and lifestyle interventions are unsuccessful