GP emergency management

An ischaemic leg: what is at the heart of the problem?

AUSTIN N. MAY, Ellen Hardy, Gordian Fulde



A 42-year-old man presents with excruciating pain in his right foot due to acute limb ischaemia. Is there a cardiac cause?

Article Extract

Mr NP is a 42-year-old married man who has no children and receives unemployment welfare payments. He has type 2 diabetes and hypercholesterolaemia, for which he has not taken any medication for three weeks. Mr NP has come to see you today with right foot pain that had a sudden onset four days ago. He has not experienced this pain before and has not had any falls or trauma to explain an injury. The pain in his foot is severe, extends to the mid-calf, is constant, waking him from sleep, and is only partially relieved by dependent positioning. He reports no claudication before this event. 

As Mr NP enters your room he is writhing in pain and hobbles to your examination table when you ask to examine him. His blood pressure is 125/85mmHg and his pulse is 70 beats per minute and regular. On examination of his leg, the skin of his foot is pale to the ankle, with mottled, dusky toes. It is cool to the touch. He has a weak right femoral pulse and popliteal pulse, but neither the posterior tibial nor dorsalis pedis pulses are palpable. Toe flexion and extension show that large muscle groups are intact, but weak fanning of his toes suggests poor small muscle group function. Beyond his pre-existing peripheral neuropathy he has decreased sensation in the right foot compared with the left. He has a blood sugar level of 28.9mmol/L. 

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