53 Year Old Male: Severe Leg Pain

This great case was sent in by faithful reader Bryan Brzycki, a Medic from Beaufort County. As usual, some minor information may be changed to protect patient confidentiality.

It's a cloudy fall morning when the tones go off and your unit is dispatched to the residence of a 53 year old male. 

When you and your partner arrive, you are greeted by the patient's wife, who leads you to your patient who is sitting on his couch in the living room.

He tells you that he was taking a shower this morning, and developed sudden onset of severe pain in his left leg. He feels discomfort throughout his leg. You inspect it, but do not notice anything abnormal. He tells you that no position seems to help the pain. You ask if he had any injuries that would account for the pain, and he can not remember anything, and that he has never felt anything like this before.

You ask about any other symptoms, and he tells you he also experienced some "mild" chest discomfort. He describes the leg pain as an 8/10, and the chest discomfort of a 3/10. You ask about any other symptoms and he denies anything else. 

He has no significant history, takes no medications, and has no allergies. In fact, he tells you he just had his annual physical last month and he was given a "clean bill of health". 

Your partner applies the leads as you get a set of vitals. The patient is agitated and uncomfortable, telling you his leg is "killing him".

  • HR:  100 and regular
  • BP:  182/92 (right arm)
  • RR:  20
  • skin: warm and moist
  • lungs: clear bilat

Here is the 12 lead:


You try to sort out what is going on as you move your patient to the back of the truck. 

Although hard to connect it to the leg pain, he did mention some chest discomfort, so you give him 4 chewable ASA and begin transport.

You decide to acquire another ECG:


What do you think is going on with your patient?



  • Dean Burns says:

    The history is concerning and suggestive of thoracic aortic dissection.  The ECG is becoming ischaemic with ST elevation in aVL and ST depression in the inferior limb leads.

  • Connie says:

    Thinking maybe DVT?  Is it the calf that's sore?  Red?  Swollen?  Bigger than the other calf??  Warm?  Broken off a clot that's travelled to the heart, perhaps??  

  • Ken says:

    Poss DVT + chest pain and some scattered inverted T’s in the presence of tachycardia. PE until proven otherwise.

  • Kristal says:

    Dvt with possible PE

  • Mike Henry says:

    I would have a high index of suspicion for an aortic pathology or a DVT, no evidence of s1q3t3 but PE completely possible the elevation is most somewhat isolated to 1 lead but there is evidence of other ischemia. The leg pain is concerning it could be abd aorta below the bifurcation especially with the contra lateral hypertension

  • Bryan says:

    DVT W/ PE until ruled out

  • Mohamed Wafiq says:

    Wells' Criteria for DVT/PE ? Yes or No. then go into Color Duplex for Lt LL venous system, TEE to rule out Aortic dissection. Plus serial resting EKG & Cr Tr follow up.

  • Steve Rydquist says:

    With limited subjective and objective about the LE, it’s kind of hard to decide whether its venous or arterial. The likelihood of a LE thrombosis is pretty high. Coupled with that, I would guess the inferior wall ischemia is secondary to an embolic occlusion.

  • Les Murrell says:

    The followup 12-Lead concerns me.  I would obtain a 15-Lead since I am seeing ST Depression in the Inferior & Anterior leads.

  • MeDs22 says:

    R sided AMI, DVT, PE, DRIVE FAST.. the no hx is random that all of a sudden he has leg pain and chest discomfort. theres mor then we can see

  • Jeff B says:

    Probably a DVT down there in his leg but i'm a little more concerned about the ECG/12-lead changes that are only 7 minutes apart..  We can attempt to rule in/out a PE (we do have a sinus tach with predominant R wave in lead I, but no RBBB, right axis deviation, Q waves in III, or T wave inversion in III).  Whats most concerning is aVL (ST segment elevation in the second 12-lead that appears quite pathological considering it wasn't there 7 minutes prior).  Kind of hard to tell with the sway in the inferior leads but it looks like we also have some more pronounced ST depression in II, III. and aVF in the second 12-lead.  Also in the lateral/high lateral leads I see shortening of the S waves which makes me suspect possible elevating in the ST segments (I, V5, V6)
     I'd like to see the third twelve lead at the hospital without any treatments :p
    Also not to sure if i'd feel safe saying "PE until proven otherwise".  With the ECG changes i'd like to suspect cardiac first until proven otherwise.
    O2 + ASA definitely, IV, NTG, and serial 12-leads.  Transport to PCI facility.

  • Darren says:

    The serial 12 leads show significant changes.  Elevation in one lateral lead is not diagnostic for a STEMI, but the presence of reciprocal inferior depression is very concerning.
    I would like to see a 15 lead with V4R, V8, and V9 present.  I am concerned about DVT (though leg exam was normal), aortic dissection with involvement of coronary vessels, and AMI.
    In any of these cases, the patient should be treated for the chest pain.  Hypertension is also a bad thing in the presence of dissection, so nitroglycerin would be a doubly good thing if that were the case.  I'd like a blood pressure in the other arm as well.
    PE could be a possibility, but no 12 lead findings that stand out; in addition, the patient is not dyspneic, though this is not a requirement.
    One thing is certain: this patient is sick and needs to see some doctors!

  • Mildred Mason says:

    My husband age 54 had pain in his thigh area when at work, no other problems.  Hx of Hypertension only, on meds and controled.  He saw the doctor who did a few test, sent him home.  A few days later we received a phone call that he had an appointment with a cardialogist.  I didn't go, though it was crap ( no other signs or symptoms).  Needless to say 6 bypasses later I was shocked.  He was not over weight, ate healthy all the right things.   Heart disease does run in his family… It was an eye opener for me.

  • Jessica G. says:

    I just found your blog – no small time commitment I'm sure! It's great review and I'm learning a lot. Thank you!
    I think the complaint sounds suspicious for aortic dissection and with the [I think] significant changes on the 2nd 12 lead I definitely would treat with ASA, NTG, MS, O2 rapid transport to PCI facility. I would like a BP on the other arm as well as posterior leads, and another 12 lead.
    SR, physiologic LAD, QT looks long to me?, early transition R wave in V2 [posterior "Q" wave? – it seems too early in the event for that] ST elevation in aVL + elevated j point [as compared to 1st EKG] and symmetrical T in lead I looks to me like the ST seg is on it's way up. I definitely see recipricol ST dep in inferior leads even accounting for baseline wander. V6 also has a very suspicious looking ST seg and symmetrical T and I suspect it would be elevated on a later 12 lead as well. Anterior leads show obvious ST depression in V3 & V4, with V2 looking like it may follow as well – antereior ischemia vs. posterior injury.
    So, I am highly suspicious of lateral/high lateral injury and possible posterior injury as well.
    Thanks again for the blog!

  • dave says:

    Most likely dissection, given sudden onset of symptoms, hypertension and ST elevation on EKG. Typically a DVT wouldn’t suddenly cause leg pain at the same time that it breaks off and goes to the lungs. Now if he said he had been having leg pain for the past couple of days, or weeks, then had the chest pain… Also, a PE could cause RV strain, maybe diffuse ST depression from demand ischemia, but won’t typically cause ST elevation. Wouldn’t expect hypertension in the setting of a large PE either, would more likely get hypotension. Of course, it could just be a good old fashion MI, and the leg pain is this dude’s anginal equivalent. Either way, it would likely be ok to hold off on the ASA for a few minutes, until you get a few more tests, if you are close to the receiving facility. As for the nitro, if it is a dissection you run the risk of increasing the heart rate and increasing stress on the wall. Classic teaching is to not lower BP until you get a beta blocker on board. If it is a good old fashioned MI, it looks like it may be inferior, with possible posterior involvement. Good change it involves the RV, nitro would be bad in that case too.

  • robert fielding says:

    Interpretation: sinus tach. St elevation avl. Net positive r waves w st depression in v2 v3. Recip changes in inferior leads. Suggestive of lateral posterior wall mi. Do serial ekgs and treat for cardiac.

  • kyle says:

    I'd like to know his SPO2, and capnography.   I would also like a 15 lead.   If I see a posterior MI, I'd follow the chest pain algorithm.   If I see more st depression, I would be on the horn to med controll for treatment plan for PE or possible aortic dissection.    (given my current protocols)

  • Mary Lynn Brzycki says:

    I know nothing about this type of trauma.  I just happen to be Bryan Brzycki's mom.  I felt I should post something.  Good work, Bryan!

  • johan theunis says:

    Vascular catastrophe, think aortic dissection
    Cardiac murmur?

  • Paul says:

    I know! I was Bryan's partner on this call. Of course, as medics we both though MI. I stepped up transport, and tried to keep it as smooth as I could. I won't spoil the outcome, but there are a few of you guys that are on the right track. I will give a hint though; I'm glad we withheld any further nitro!

  • B Brzycki says:

    Paul, I obtained the treatment records fom the ER and OR (with pt consent) and Nitro saved this guy. If we carried a Nitro drip I would have hung one. Easy to control and safer to achieve a therapeutic dose for his CP. My tratment with the CP protocol was really what saved this guy. 

  • Sheila says:

    Q.posterior mi and consider aaa if obs or presentation supported it.

  • Paul says:

    High lateral wall infarction based on significant ST elevation in AvL(1/2 the height of the QRS); likely with posterior involvement based on the ST depression in V2-V3. I find it interesting that the first 12-lead (although of poor quality) shows ST elevation in V1, but the subsequent 12-lead does not.

    If anyone has not heard of Dr. Stephen Smith and read his books on EKG interpretation, I highly recommend it. He is also featured in an EMCrit podcast that explains WHY this 12-lead is a classic example of a LWMI, and also explains why the millimeter criteria are irrelevant and arbitrary.

    I suspect the LWMI here is due to an embolus that has migrated. Oxygen, 2×16-18G IV’s, aspirin, nitrates, and morphine. I would also give 5mg of metoprolol to try and get some rate control and additional vasodilation going for this patient. Definite cath.

  • AxelF says:

    Had a patient yesterday with exactly the same symptoms (except he was bradycardic at 40 bpm) after lifting a dishwasher.
    In his case it turned out to be aortic dissection, so I wouldn't be surprised if that's the case here too.
    Though I'd like some more information about the moment of onset. Was he just taking a shower, or could there have been any sudden movements, heavy lifting, bowel movement or  physical exertion of some sort?

  • Floyd says:

    Im going to guess a decending aortic aneurysm. ECG changes usually occur more in the proximal aneurysm's but it is possible in type B or the distal ones. That could easily explain the extreme leg pain and chest pain w/o any specific symptoms for a PE.

  • ChCherkezoff says:

    I don't think that the info you gave is enough to place a diagnosis but if we're guessing I'd say acute MI (first diagonal of LAD – isolated aVL st elevation + inferior lead st depressions) with subsequent arterial embolisation.

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