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You have been asked to see a 60 year old lady called Ira Itis, who has made a GP appointment to discuss the recent pains she has been getting in her legs.

Please take a history from Ira and explore any risk factors she may have. Following this please perform the appropriate examination on the patient.

You are Ira, a 60 year old retired school teacher, who has been experiencing pains in both legs for the past four months.

HPC – it happens in both calves, when walking around. When it started about four months it tended to come on after about a quarter a mile, but in the last month it has been for much shorter distances (around 100 yards). Once it comes on, it will subside if you sit down or rest them for two or three minutes. In the last week you’ve even noticed some pain when not walking around at all! And last night the pain actually woke you up. You realised this wasn’t quite right, and decided to see someone about it. You have no numbness, tingling or sensation changes with your legs. You haven’t noticed them looking very different, although they do often feel cool and you don’t like wearing skirts without tights as they can look “quite pasty”.

ICE – you live alone, and so if this leg pain stops you from getting about, you’ll have no way of going shopping, seeing a couple of local friends or making your weekly visit your poetry recital class. Your friends are also “getting on” and so you feel you can’t rely on them for help getting about, and have no close family nearby. One of your friends said she was given a night tablet for leg cramps and you wonder if this is what is also needed for you, plus some tablets for the pain.

PMH - you have had three heart attacks in the past five years, and had stents put in after the last one last year. Since the first heart attack you were started on aspirin, but don’t always take it. You take tablets for your diabetes and high blood pressure. You should also take a statin at night for your cholesterol but often forget.

SH – you used to smoke about 20 a day for 40 years but stopped after your first heart attack five years ago. You enjoy a glass of sherry at the weekly poetry recital, and often live off ready meals for convenience.

FH – your mother in her 60s of a heart attack, and your father died a little older of a stroke.

The student should take a detailed history of the leg pain, eliciting the recent symptoms of rest pain and night pain, as well as the risk factors in her past medical, family and social history. They should then do a full peripheral vascular examination, covering both upper and lower limb. The student should summarise and conclude this patient is most likely has peripheral vascular disease, and that acute limb ischaemia would be the biggest concern for this patient due to the recent progression of symptoms (+/- examination findings) Examples for discussion may include: - What are the signs and symptoms of acute limb ischaemia? - What is an ABPI and how is this measured? What would a reading of 0.2 suggest? - What imaging can be used for this condition? - How is this condition managed? - What are the complications of the surgical management for this condition?