History Taking · Foundation · Cardiovascular

Leg Pain on Walking in a 76-Year-Old Man

Practise this PLAB 2 history taking station on Peripheral Arterial Disease. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the Vascular Surgery Clinic. Mr Gordon Smith, a 76-year-old man, has been referred because of leg pain when walking. He reports he can only walk about 50 metres before having to stop due to calf pain. He has also noticed his feet are cold. Please take a focused history and discuss initial assessment and investigations for peripheral vascular disease.

Background notes: PMH: Hypertension, Type 2 diabetes, Hypercholesterolaemia, Previous MI, CKD stage 3b (eGFR 38)

What this station tests

  • Recognising the classic features of intermittent claudication: distance-dependent, reproducible, relieved by rest, calf location suggesting femoropopliteal disease
  • Distinguishing claudication from critical limb ischaemia by actively screening for rest pain, night pain, skin changes, and tissue loss
  • Comprehensive cardiovascular risk factor assessment in a patient with established multi-vessel atherosclerotic disease (previous MI, now PAD)
  • Explaining supervised exercise therapy as first-line treatment for claudication, not just 'walk more'
  • Assessing functional and psychosocial impact: a widower living alone whose independence depends on his ability to walk

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Claudication history requires establishing the reproducible, distance-dependent pattern that distinguishes vascular pain from musculoskeletal, neurogenic, or venous causes. Mr Smith is 76, a widower living alone, referred because he can only walk 50 metres before stopping due to calf pain. Open with: 'Tell me about what happens when you walk.' He will describe cramping calf pain at a predictable distance, relieved by 2 to 3 minutes of rest, after which he can walk the same distance again. This is textbook intermittent claudication.

Core approach

The pain is in his left calf ('like the muscle is tired and tight'), started six months ago, is gradually worsening, and his right leg is now developing milder symptoms. Pain onset is distance-dependent: 40 to 50 metres, slightly further at a slow pace. Complete rest relief within 2 to 3 minutes. This reproducible pattern is the hallmark of claudication and distinguishes it from spinal claudication (which relates to posture, not distance) and musculoskeletal pain (which does not have the consistent walk-rest-walk pattern).

Screen actively for critical limb ischaemia, which changes urgency entirely. Rest pain: none. Night pain: feet are cold and uncomfortable but no actual pain. Skin changes: feet look pale, left colder than right. Hair loss below the knees: 'Yes, come to think of it.' No ulcers, no tissue loss. These features confirm moderate PAD (claudication) rather than critical ischaemia.

Mr Smith has extensive cardiovascular disease: hypertension, type 2 diabetes, hypercholesterolaemia, previous MI, and CKD stage 3b. PAD is a manifestation of the same systemic atherosclerosis. Check his secondary prevention: is he on an antiplatelet, statin, ACE inhibitor? Check smoking status (critical, as cessation is the single most effective intervention for PAD).

Assess functional and psychosocial impact. He cannot walk to the shops, has given up gardening, and is losing independence. His son helps with shopping. He is frustrated and low in mood. For a widower living alone, loss of mobility directly threatens his ability to live independently.

Closing and safety netting

Explain the diagnosis by connecting it to what he already knows: 'The narrowing in your leg arteries is caused by the same process that caused your heart attack, a build-up in the artery walls.' Outline assessment: ABPI today (explain: comparing blood pressure at ankle and arm), blood tests, and likely a duplex ultrasound scan.

Management has three pillars. First and most important: smoking cessation (if applicable) and cardiovascular risk factor optimisation. Second: supervised exercise therapy, a formal vascular walking programme that can double walking distance. This is first-line treatment, not just 'walk more.' Third: if exercise and risk factor modification are insufficient after 3 to 6 months, angioplasty or bypass may be considered.

Address his independence concern: 'With the right treatment, particularly the exercise programme, most people see significant improvement.' Foot care for a diabetic patient with PAD: inspect daily, avoid walking barefoot, report any injury. Safety net: pain at rest, colour changes, wounds, or skin breakdown on feet means urgent contact.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for peripheral arterial disease. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Systematic claudication history: distance, reproducibility, rest relief, bilateral involvement. Active screening for critical ischaemia: rest pain, night pain, hair loss, skin colour, ulceration. Comprehensive cardiovascular risk assessment: smoking, diabetes control, lipids, BP, medication review. Noting hair loss and pallor as peripheral signs.

Costs marks: Not establishing the distance-dependent, reproducible pattern. Not screening for rest pain and critical ischaemia features. Not asking about smoking status. Incomplete medication history.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Explaining ABPI as a diagnostic tool. Three-pillar management: risk factor modification (smoking cessation, statin optimisation, diabetic control), supervised exercise therapy as first-line, and revascularisation as second-line. Diabetic foot care advice. Specific safety netting for progression to critical ischaemia.

Costs marks: Jumping straight to surgery as the solution. Not mentioning supervised exercise therapy. Vague risk factor advice. No diabetic foot care for a patient with diabetes and PAD. No safety netting for critical ischaemia progression.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing his fear of losing independence. Acknowledging the loss of activities he enjoyed (gardening, walks with his late wife). Providing hope about improvement with exercise therapy. Sensitive exploration of his mood and social isolation.

Costs marks: Focusing purely on the vascular problem without exploring impact on daily life. Not acknowledging his widower status and its relevance. Dismissing his functional limitation as 'not urgent because there's no rest pain.'

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not distinguishing claudication from critical limb ischaemia. The management is completely different: claudication is managed with exercise therapy and risk factor modification, while critical ischaemia requires urgent revascularisation. Candidates who do not ask about rest pain, night pain, and skin changes cannot make this distinction.
  2. Forgetting to assess the wider cardiovascular risk profile. Mr Smith has had an MI. He has PAD. His other arteries (coronary, carotid, renal) are also likely affected. Candidates who treat the leg in isolation without reviewing his secondary prevention medications miss the systemic nature of atherosclerotic disease.
  3. Not addressing the psychosocial impact. For a 76-year-old widower living alone, claudication is not just a leg problem: it is a threat to independence, self-sufficiency, and quality of life. Candidates who take a technically correct history but ignore his fear of dependence score poorly on Domain 3.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this peripheral arterial disease station?

Claudication history requires establishing the reproducible, distance-dependent pattern that distinguishes vascular pain from musculoskeletal, neurogenic, or venous causes. Mr Smith is 76, a widower living alone, referred because he can only walk 50 metres before stopping due to calf pain.

What does a strong performance look like to the examiner in this station?

Strong performances show: Systematic claudication history: distance, reproducibility, rest relief, bilateral involvement. Active screening for critical ischaemia: rest pain, night pain, hair loss, skin colour, ulceration. Weak performances: Not establishing the distance-dependent, reproducible pattern. Not screening for rest pain and critical ischaemia features. Not asking about smoking status.

What is the biggest pitfall in this peripheral arterial disease station?

Not distinguishing claudication from critical limb ischaemia. The management is completely different: claudication is managed with exercise therapy and risk factor modification, while critical ischaemia requires urgent revascularisation. Candidates who do not ask about rest pain, night pain, and skin changes cannot make this distinction.

How should I prepare for peripheral arterial disease if I have never seen it in practice?

Structure beats experience here. Focus on distinguishing claudication from critical limb ischaemia by actively screening for rest pain, night pain, skin changes, and tissue loss. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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