Peripheral arterial disease and ulcers Quiz: Ace Your Exams

A 70-year-old man presents to the emergency department for bilateral leg pain and a lesion on the right foot. The patient is a retired school teacher and enjoys gardening in his spare time. Recently, he has had to stop his gardening every few minutes and rest due to intermittent leg pain and cramping. Until three weeks ago, the pain was relieved by resting. However, now it occurs even when sitting down and resting, and he also has associated bilateral foot pain. Two weeks ago, he noted a lesion on his right toe that has remained stable. There is no associated cough, dyspnea, orthopnea, or chest pain. The patient has hypertension that is well controlled with enalapril. He has smoked cigarettes for 10 years and is currently trying to quit. Temperature is 37.0°C (98.6°F), pulse is 90/min, blood pressure is 124/86 mmHg, and SpO2 is 98% on room air. On physical examination, there is a nicotine patch on the patient’s right shoulder. The lower extremities are cool and hairless bilaterally. There are no palpable distal pulses. There is a solitary ulcer with punched-out edges and a dry base on the big right toe that is painful to touch. Bilateral ankle-brachial index is 0.7. Based on this patient’s history and findings, which of the following is the most likely diagnosis?