A 68-year-old man, ex-smoker, with a history of hypertension, hypercholesterolemia, and intermittent
claudication secondary to severe aorto-iliac occlusive disease, was evaluated by a cardiologist for exertional
right-shoulder pain of one year's duration. The pain would typically last approximately five minutes and
resolve with cessation of activity. He experienced no similar episodes at rest. There was no retrosternal chest
pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, palpitations, transient ischemic attacks,
syncope, or pre-syncope. His medications included Norvasc, Prinivil, Novoflupam, Nitrospray, Novo-Timol,
Pravacho, Entrophen, and Tylenol. Family history was positive for coronary artery disease.
On physical examination, the patient was in no apparent distress with a blood pressure of 160/80 in both arms
and a regular pulse of 70. There was a left carotid bruit. Femoral pulses were nearly absent bilaterally. Heart
sounds were normal, with no murmurs, and there were no signs of heart failure. EKG showed normal sinus
rhythm and no evidence of ischemia or previous infarction. However, thallium scan revealed a fixed deficit in
the inferior wall territory.
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