Peripheral vascular disease: Clinical

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Peripheral vascular disease: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 75-year-old man comes to the clinic with persistent leg pain with exertion. Three months ago, the patient was found to have an ankle-brachial index of 0.6, and he was started on atorvastatin, chlorthalidone, and aspirin. Since then, the patient has successfully quit smoking and has participated in a supervised exercise therapy program where he has achieved a 10 lb (4.5 kg) weight loss. The pain, characterized by aching in the right thigh and buttock after walking more than 3 blocks, has not improved. The patient’s temperature is 37.0°C (98.6°F), pulse is 80/min and regular, respirations are 20/min, blood pressure is 130/75 mmHg, and BMI is 32 kg/m2. Pulses in the right femoral artery are diminished compared to the left. Which of the following therapies is most appropriate for this patient?  


Peripheral vascular disease is an abnormal narrowing of arteries other than the ones that supply the heart or brain, and it most often affects the ones in the legs.

Risk factors include being older than 60 years, smoking, hypertension, hyperlipidemia, diabetes, and metabolic syndrome.

The most common underlying mechanism of peripheral artery disease is atherosclerosis, which results in the accumulation of lipid and fibrous material between the layers of the arterial wall.

Eventually, the affected artery becomes progressively narrower, and this may lead to pain, ulceration, and even gangrene.

Now, most people with peripheral vascular disease actually don’t have symptoms until occlusion becomes significant, which is when 70% of the vessel lumen is obstructed.

Symptoms include intermittent claudication, which includes pain, numbness, or tiredness in the legs during walking or standing, and is relieved by rest.

This is because the blood supply may be enough to meet the muscle needs at rest, but not the increased needs during activity, leading to ischemia – so basically, occurs when oxygen demand is greater than oxygen supply.

The perceived level of symptoms from intermittent claudication can be mild to extremely severe depending on the degree of blood supply.

Intermittent claudication can present unilaterally or bilaterally, as buttock and hip, thigh, calf, or foot pain, singly or in combination.

In addition, pulses in one or both groins are diminished, and bilateral aortoiliac disease that is severe enough almost always causes erectile dysfunction.

The triad of intermittent claudication, absent or diminished femoral pulses, and erectile dysfunction is known as Leriche syndrome.

Location of pain depends upon the artery involved. Lower aorta or iliac artery involvement causes pain in the hips and buttocks.

Iliac or common femoral artery involvement causes pain in the thigh.


Peripheral vascular disease (PVD) is a group of diseases that affect the circulation in the blood vessels outside of the heart and brain. PVD can cause the blood vessels to get narrowed or blocked, leading to poor circulation and possible ischemia of the affected body parts. Symptoms depend on the affected organ and may include leg pain, cramping, and fatigue. It is commonly associated with smoking, high blood pressure, diabetes, and high cholesterol. Treatment options for PVD include lifestyle changes, medications, and surgery.


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