As you enter the room you see a 63 y/o male lying still on the cot, grimacing in pain, slightly diaphoretic. His history is limited because of his pain and he provides only minimal responses to questions.

While walking down the street he started to have an aching in his back that progressed down his leg. This was about one hour ago. The pain continued to get worse, and now the pain is severe. The location of the pain is his lumbar back area and his entire left leg. Movement does not make the pain worse. No history of previous similar symptoms.

ROS: No fevers, chills, nausea, vomiting, diarrhea, headache, rashes. He did note some chest pain earlier, and took two nitroglycerine tabs and it eventually went away. No chest pain now. No shortness of breath, cough. No abdominal pain, no dysuria.

PMH: Heart attack 2 years ago (1 stent), HTN, diet controlled diabetes.

SH: Smoker for >40 years; Social alcohol.

PE: Very anxious, diaphoretic man, wincing in pain. (He appeared so uncomfortable that before I finished obtaining a history, I left to ask a nurse to start a line and give him 10 mg of morphine).

BP: 165/100, RR 24, HR 90, Temp 98Fpo

HEENT: Unremarkable, no JVD

Heart: RRR, no murmurs

Lungs clear bilateral

Abdomen: Soft, some tenderness is noted in the periumbilical area. No scars. No distension.

Ext: Upper extremities normal. Left lower leg cool to touch. It is pale, and there is no palpable pulse at the dorsalis pedis, posterior tibialis, or popliteal area. There is a very faint pulse at the femoral area that is obtained only by Doppler. Right leg has easily palpable pulses throughout. The left leg is paretic, and the patient can only wiggle toes and lift the leg about 4 inches off the cot for a second before it collapses back to the cot. Decreased sensation to the entire leg is also noted.

1. What is the diagnosis, and what is one potential etiology?

2. Can ultrasound help here?

3. What are your orders and who you gonna call?

 

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