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.