Leg Pain in a 62-yr-old Man

Past Medical History

  • Medical history: The patient has had type 2 diabetes for 5 yr, controlled by diet. He does not measure glucose levels at home. His glucose and HbA1c levels were last checked 6 mo ago, but he does not know the results. Coronary artery disease was diagnosed 7 yr ago requiring coronary artery bypass grafting (CABG). No current angina; no history of myocardial infarction. Hypertension and hypercholesterolemia since age 50, controlled on medications. No history of cancer, HIV, blood clots or clotting disorder. No recent hospitalizations.

  • Surgical history: CABG 7 yr ago, with harvesting of his right saphenous vein.

  • Medications: Hydrochlorothiazide 25 mg once/day, enalapril 40 mg once/day, aspirin 81 mg once/day, pravastatin 40 once/day.

  • Allergies: No known drug allergies; no seasonal allergies.

  • Family history: Mother alive; age 80 with hypertension, type 2 diabetes, and high cholesterol. Father died at age 64 of myocardial infarction.

  • Social history: Employed as a police officer, has been going to work as usual until today. He plays squash and/or basketball twice a week. He adheres to a low-fat diet and consumes 2 to 3 alcoholic drinks/wk. He smoked 1 pack of cigarettes daily for 20 yr but quit at age 44. Denies other recreational drug use, including parenteral use or skin-popping. He has not traveled outside the northeast US in more than 10 yr. No pets. Up to date on vaccines.