Patient Requires Amputation Following Delayed Recognition Of Vascular Complications

This case involves a 56-year-old male smoker who presented to the emergency room with complaints of lower extremity pain and a pulsating sensation in his leg. During the first presentation, a venous doppler was performed that was negative for deep vein thrombosis. No arterial pulses were checked prior to the patient’s discharge. He was subsequently seen in the pain medicine clinic with similar complaints with radiation to the hip. The physician assistant documented diminished pulses. A CT lumbar spine showed no acute disease process and the patient was advised by the physician assistant to follow up with his primary care physician to rule out shingles. Two weeks later, the patient presented to a second emergency room with a darker and cool right foot and was diagnosed with a right arterial iliac thrombus. He was immediately transferred to a medical center for an emergency vascular procedure. The patient returned to the operating room several times post-operatively due to absent pulses and eventually required a below the knee amputation.

Question(s) For Expert Witness

1. Do you routinely evaluate and treat patients with this clinical presentation?

2. What are the common complaints associated with peripheral arterial occlusion?

3. What is the differential diagnosis between left arterial iliac thrombus and shingles?

Expert Witness Response E-006207

I routinely evaluate and treat patients with this clinical presentation. The most common complaint would be claudication, that is, pain with activity, usually in the calf but can be elsewhere, that is relieved rather quickly with rest. This can vary from patient to patient of course. Shingles usually start with a sort of "electric-like" neuropathic pain, often described as tingling of the surface of the skin. Then patients may develop a rash. I have never seen a case, nor do I know of any association of shingles with diminished pulses in the leg. Diminished pulses are always arterial occlusion until proven otherwise. The presence of claudication makes that diagnosis even more likely. This man smokes, which puts him at risk for vascular problems in and of itself. Ruling out DVT was a valid step, but not recognizing the potential of an arterial problem in the setting of diminished pulses would be malpractice. I cannot see how that diagnosis goes with absent or diminished pulses.