A 62-year-old man presents with painful cramps in his left lower leg that began about 6 months earlier and have recently become more frequent. The cramps occur with vigorous walking and cease when he stops for several minutes. He has experienced them during the active aspects of his work as a deli owner and when walking uphill while playing golf. He does not have cramps at night while asleep. He has no chest pain or symptoms of congestive heart failure.
The patient has mild hypertension that is well controlled by low doses of a β-blocker. His blood glucose level has on occasion been in the "borderline diabetes" range but has always normalized with weight loss. He has smoked 1 or more packs of cigarettes a day for at least 30 years and has 1 alcoholic drink daily.
This well-appearing man has normal vital signs, including a blood pressure of 132/76 mm Hg. Head, ears, eyes, nose, and throat are normal. Carotid pulses are strong and symmetrical without bruits. Chest is clear; heart rate is 64 beats per minute and regular, without murmurs or gallops. Abdomen is soft, without masses or organomegaly. Extremities are of normal color and temperature bilaterally, with symmetrical hair distribution. Femoral pulses are strong and symmetrical bilaterally, without bruits; however, the left popliteal pulse is diminished compared with the right popliteal pulse and also compared with the left dorsalis pedia and posterior tibial pulses.
A hemogram is normal, as are the results of a serum chemistry panel. A random blood glucose measurement is 98 mg/dL. The total cholesterol level is 220 mg/dL, with a low-density lipoprotein cholesterol level of 167 mg/dL and a high-density lipoprotein level of 45 mg/dL.
Which of the following is the most appropriate next step?
A. Initiate aspirin, 325 mg/d, and clopidogrel, 75 mg/d.
B. Obtain an MRI study of the lumbosacral spine.
C. Order Doppler ultrasonography of the leg veins and a plasma D-dimer assay.
D. Perform pressure measurements and calculate the ankle-brachial index.
(Answer on next page.)
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