47. Leg pain/swelling Flashcards
Differentials for leg pain/swelling
Venous
- DVT
- Post-thrombotic syndrome
- Venous insufficiency
Arterial (PAD)
- intermittent claudication
- Critical limb ischaemia
- acute limb ischaemia
Infection
- cellulitis
- septic arthritis/osteomyelitis
what score should you calculate if DVT is a ddx
Two-level DVT Wells score
DVT likely: 2 points or more
DVT unlikely: 1 point or less
how many points is ‘likely’ for dvt on two level wells score? management
2 or more
1. a proximal leg vein ultrasound scan should be carried out within 4 hours
- if +ve = start anticoagulant
- if -ve = a D-dimer test should be arranged. A negative scan and negative D-dimer makes the diagnosis unlikely and alternative diagnoses should be considered
- If proximal leg vein ultrasound cannot be performed within 4 hours then a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
- rivaroxaban or apixaban
- if the scan is negative but the D-dimer is positive:
stop interim therapeutic anticoagulation
offer a repeat proximal leg vein ultrasound scan 6 to 8 days later
how many points is ‘unlikely’ for dvt on two level wells score? management?
- perform a D-dimer test
- this should be done within 4 hours. If not, interim therapeutic anticoagulation should be given until the result is available
if the result is positive then a proximal leg vein ultrasound scan should be carried out within 4 hours
if a proximal leg vein ultrasound scan cannot be carried out within 4 hours interim therapeutic anticoagulation should be administered whilst waiting for the proximal leg vein ultrasound scan
if the result is negative then DVT is unlikely and alternative diagnoses should be considered
How long should anticoagulation be continued DVT
provoked - 3 months
active cancer - 3-6 months
unprovoked - 6 months
define provoked dvt
due to an obvious precipitating event
e.g. immobilisation following major surgery.
The implication is that this event was transient and the patient is no longer at increased risk
what score should be used to assess bleeding risk anticoagulation
ORBIT score
presentation post-thrombotic syndrome
post dvt
Venous outflow obstruction and venous insufficiency result in chronic venous hypertension.
The resulting clinical syndrome is known as post-thrombotic syndrome. The following features maybe seen:
painful, heavy calves
pruritus
swelling
varicose veins
venous ulceration
management post-thrombotic syndrome
compression stockings
what is peripheral arterial disease
Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas.
It usually refers to the lower limbs, resulting in symptoms of claudication.
what is intermittent claudication? features
is a symptom of ischaemia in a limb, occurring during exertion and relieved by rest.
It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
what is critical limb ischaemia? features?
end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.
The features are pain at rest, non-healing ulcers and gangrene. There is a significant risk of losing the limb.
what is acute limb ischaemia
Rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
define gangrene
death of the tissue, specifically due to an inadequate blood supply
non-modifiable risk factors peripheral arterial disease
Older age
Family history
Male
