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Year 4 - ACC Core Condition > Atraumatic leg pain 1 > Flashcards

Atraumatic leg pain 1 Flashcards

1
Q

What is the most common of acutely ischaemic leg?

A 
Thrombus - 40% of the cases 
Emboli - 38% 
Angioplasty occlusion 15% 
Trauma 
Compartment syndrome - rare
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2
Q

What is the symptoms of acutely ischaemic leg

A

6 Ps

Pale 
Pain 
Pulseless 
Paraesthetic 
Paralysed 
Perishingly cold
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3
Q

What other differentials can lead to mis-diagnosis of acutely ischaemic leg?

A

Cellulitis

Gout

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4
Q

Examination of the acutely ischaemic leg?

A

A full cardiovascular examination

  • cardio exam for heart valve disease due to embolus damage
  • abdo exam for aneurysm
  • peripheral vascular examination

Try to identify all 6 Ps

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5
Q

What is the classification used to classify ischaemic leg?

A

Rutherford classification

Classified into 
viable
threatened (salvageable if treated) 
Threatened (salvageable with immediate reconstruction) 
Irreversible

It looks into capillary return, motor(paralysis), sensory(paraesthetia), arterial Doppler signal, venous Doppler signal

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6
Q

Ix of acutely ischaemic leg

A

ECG - identity cardiac arrhythmia or an acute cardiac event - source of emboli

Bloods

  • FBC - haematological disorder predisposing to thrombus
  • U + E - check K+ which can be raised if muscle necrosis has occurred
  • glucose - diabetes (RF)
  • creatinine kinase - raised in muscle necrosis
  • clotting - clotting disorders - check before prescribing heparin
  • G+S - for surgery

ABG - may show acidosis secondary to ischaemia

Imaging - angiograms, MR angiography or CT angiography

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7
Q

management of acutely ischaemic leg

A

analgesia - IV morphine

oxygen

heparin 5000 units (IV unfractioned) to prevent propagation of thrombosis

IV fluids - avoid Hartmann’s due to potassium

refer to vascular surgeons

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8
Q

what is cellulitis

A

it is an acute-spreading bacterial infection of the dermis and subcut tissue

usually there is a wound, ulcer or dermatitis

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9
Q

what are the common pathogen of cellulitis?

A

strep pneumoniae

H.influenza (in paeds)

Gram-ce baccili

anaeorbes

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10
Q

symptoms of cellulitis

A

rubor - erytherma
dolor - pain
tumor - swelling
calor - heat

systemic effect - fever, malaise, nausea, rigors

confusion in elderly

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11
Q

examination finding of the cellulitis?

A

peripheral vascular examination to rule out other DCT

normal obs

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12
Q

Ix for cellulitis

A

primary care - clinical diagnosis

secondary

  • bloods - raised WCC, CRP, fasting blood glucose, lipids and cholesterol
  • blood culture
  • X-ray, CT/MRI if there are any concern of underlying infection
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13
Q

management of cellulitis

A

general management

  • elevate leg
  • analgesia
  • treatment for tetanus vaccination

ABX
- if minor - PO flucloxacillin or erythromycin (if allergy to penicillin)

if severe - IV flucloxacillin, clindamycin IV (if allergic)

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14
Q

prognosis of cellulitis

A

usually recovers nicely

recurrent cellulitis in 11-16%

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15
Q

cause of deep vein thrombosis

A

influence to the Virchow’s triad

  • stasis
  • hypercoagulopathy
  • vessel wall injury/atherosclerosis

blood clot in the deep vein of the leg

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16
Q

what is the risk of DVT

A

2.5-5% lifetime risks

17
Q

what is the symptoms of DVT?

A

pain - unilateral most likely

fever

unilateral pitting oedema

erythema of the affected calf area

local tenderness

50% of pt present with SOB (PE until proven otherwise)

18
Q

examination findings of DVT

A
  • > 3 treat as a DVT – preform a USS to confirm, D-dimer used to risk stratify
  • 1-2 – do a d-dimer if -ve then sufficient to rule out DVT, +ve – USS scan, consider LMWH
  • 0 – do a D-Dimer test. If negative then DVT is unlikely. If positive then treat as DVT and do a compression USS to confirm
19
Q

what are the criteria for well’s score for DVT

A

total of 10 criteria

1) active cancer - ongoing, last 6 months, palliative
2) immbolisation
3) bedridden > 3 days/major surgery in the last 12 months
4) local tenderness along the deep venous distribution
5) entire leg wollen
6) > 3cm size inc in the affected calf
7) pitting oedema in the affected side
8) collateral superficial vein
9) previous documented DVT
10) other diagnosis as likely as DVT (-2)

20
Q

Ix for DVT

A

guided by Well’s score for DVT

USS of calf/leg

d-dimer

calf measurement

ECG for S1Q3T3

venography - dye injected into the foot to visualise blocked vein

21
Q

management of DVT

A

to avoid PE - main aim

6 weeks of LMWH - enoxaparin +/- warfarin (3 months [post-op, 6 monthe if no cause, lie-long if recurrent DVT)

can use IVC or do thrombolytic procedure if haemodynacially unstable

22
Q

what are the different types of crystal arthritis

A

gout - deposition of urate crystals

psudogout - deposition of calcium pyrophosphate crystal

23
Q

what birefringent does gout has?

A

-ve - needle shape

24
Q

what birefringent does psudogout has?

A

+Ve - rhomboid shape

25
Q

aetiology of gout?

A

high concentration of uric acid in the blood or due to high dietary intake eg meat and alcohol intake

26
Q

symptoms of gout?

A

usually monoarthritis

presence of tophi (deposition of urate crystal in the skin)

severe pain that can wake patient up during the night

red hot swollen and tender joint

most patient will have second attack in 18 months

27
Q

examination of gout?

A

warm, tender and painful joint

pyrexia - due to the neutrophile acton of trying to engulf the uric acid

urolithiasis in the kidney or bladder - so symptoms of those as well if severe pyelonephritis

28
Q

Ix of gout

A

serum urate - will only be raised in 60%

WCC - raised
CRP - raised

synovial fluid - -ve birefreingent and high leukocyte count

X-ray - maybe used in patient with long standing of the gout

29
Q

management of gout

A

acute

  • analgesia - NSAIDs
  • IM/intra-articular steriod
  • anti-urate binding agents - colchicine - sued with NSAIDS for analgesia / used when NSAIDs not tolerated

Only allopurinol in chronic treatment to prevent urate acid synthesisby inhibiting xanthene oxidase

30
Q

what can colchicine cause?

A

GI upset and NSAID contra-indicated

31
Q

what is the most common joint to have gout?

A

MTP

32
Q

what is septic arthritis

A

it is bacterial infection of a joint or multiple joints at the same time (which is rare)

33
Q

what is the most common pathogen that causes septic arthritis

A

Staph Aureus

34
Q

what pathogens causes septic arthritis

A

Staph aureus

rarer causes - N.gonorrhoea

35
Q

what is the most commonly affected joints due toe septic arthritis

A

hip then shoulder, ankle and wrist

36
Q

symptoms to septic arthritis

A

fever/rigor

red, hot, swollen joints usually only a single joint

pain on movement so people usually try not to move

can have pre-infective injury to the joint

37
Q

examination of septic arthritis

A

single, red, hot, swollen joint (can have multiple joints)

38
Q

Ix of septic arthritis

A

FBC - WCC raised
CRP - raised
blood culture - often +ve (can lead to speticaemia)

aspirate joint

  • synovial fluid for urgent MC+S
  • luekocytes raised due to mycobacterial infection
  • polarising microscopy to exclude gout
  • must be done prior to ABx

Swabs from skins wounds and throat, sputum and urine

39
Q

management of septic arthritis

A

flucloxacillin
vancomycin if MRSA
cefuroxime if elderly/recurrent UTI/abdo surgery

Year 4 - ACC Core Condition (3 decks)

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