A 62-year-old man with known diabetes mellitus and hyperlipidemia comes to the physician with right hip pain for the last 3 months. The pain is aching, brought on by walking (especially uphill), and goes away quickly with standing still. It is sometimes accompanied by leg weakness, causing the patient to hold on to stationary objects.
The patient's other medical problems include gallstones, hyperlipidemia, benign prostate hyperplasia, and erectile dysfunction. He takes long-acting insulin at night. His dose of simvastatin was recently increased due to an elevated LDL cholesterol level.
Which of the following physical findings is most consistent with this patient's diagnosis?

Question

A 62-year-old man with known diabetes mellitus and hyperlipidemia comes to the physician with right hip pain for the last 3 months.  The pain is aching, brought on by walking (especially uphill), and goes away quickly with standing still.  It is sometimes accompanied by leg weakness, causing the patient to hold on to stationary objects.
The patient's other medical problems include gallstones, hyperlipidemia, benign prostate hyperplasia, and erectile dysfunction.  He takes long-acting insulin at night.  His dose of simvastatin was recently increased due to an elevated LDL cholesterol level.
Which of the following physical findings is most consistent with this patient's diagnosis?

Quizplus · Accepted Answer

11ec193a_9753_ed5a_853d_0d3fe623d7cb_MD0002_00 This patient's pain with walking uphill and relief with rest suggest intermittent claudication due to occlusive peripheral artery disease (PAD) (Table). Localized hip or buttock area pain suggests aortoiliac occlusive disease. Patients typically present with aching pain and thigh or hip weakness while walking. Leriche's syndrome is a triad of claudication, diminished femoral pulses, and erectile dysfunction due to severe aortoiliac occlusive PAD. This patient's atherosclerotic risk factors of diabetes and hyperlipidemia place him at high risk for PAD. Physical examination in PAD patients may show diminished or absent femoral pulses, bruits over femoral or iliac arteries, cool extremities, prolonged venous filling time, skin or muscle atrophy, prolonged wound healing, and foot pallor with elevation of the affected leg (Buerger's test). (Choice A) Dorsal column disease of the spinal cord (eg, vitamin B12 deficiency) may present with sensory loss with a disproportionate loss of vibration sense and proprioception. Sensory loss is usually not present on physical examination in PAD patients. (Choice C) Osteoarthritis of the hip usually presents with hip pain on passive flexion. Osteoarthritis pain is usually worse with ambulating after a long rest or in the morning after awakening. In addition, the pain usually does not improve as quickly with rest as seen in this patient. (Choice D) Lumbar spondylosis or degenerative arthritis of the lumbosacral spine can lead to decreased lumbar spine mobility due to disc bulging or spinal stenosis compressing the nerve roots. Patients may present with neurogenic claudication or pseudoclaudication (worsening pain with standing or erect posture, but relieved with sitting or lying down), focal weakness, or sensory loss in the distribution of 1 or more spinal nerve roots. (Choice E) Muscle tenderness can be due to viral infections, systemic rheumatic conditions (eg, polymyositis/dermatomyositis), fibromyalgia, hypothyroidism, and medications (eg, statins). Severe PAD can lead to lower-extremity muscle atrophy but usually does not cause muscle tenderness. Educational objective: Occlusive peripheral artery disease typically presents with intermittent lower-extremity claudication increased with walking and relieved promptly with rest. Physical examination may show diminished or absent femoral pulses, bruits over femoral or iliac arteries, cool extremities, prolonged venous filling time, skin or muscle atrophy, prolonged wound healing, and foot pallor with elevation of the affected leg. __________ References: Diagnosis and management of peripheral arterial disease. (http://www.ncbi.nlm.nih.gov/pubmed/22893640)

A 62-Year-Old Man with Known Diabetes Mellitus and Hyperlipidemia Comes