Atraumatic Leg Pain

Question 1

Investigations in acutely ischaemic limb? + Interpretation of results

Answer 1

ABPI - Ankle Brachial Pressure Index
1.3+ = vessel hardening
1 - 1.2 = normal
0.9 - 1 = acceptable
0.8 - 0.9 = some arterial disease
0.5 - 0.8 = moderate arterial disease
<0.5 = severe arterial disease

Question 2

Management of acutely ischaemic limb?

Answer 2

Assessment of viability of limb - if within 6hrs / sensory motor still in tact - urgent revascularisation
If not - amputation
Analgesia
Aspiring/clopidogrel
Heparin
Risk factor optimisation

Question 3

Difference between cellulitis and erysipelas

Answer 3

Cellulitis = infection of dermis + sub-cut tissues
- rash poorly demarcated

Erysipelas = infection of the upper dermis + systemically - rash is fiery red, well circumscribed

Question 4

Common causative organisms of cellulitis

Answer 4

Streptococcus - most common

Staph aureus

Question 5

Management of Cellulitis

Answer 5

Flucloxacillin, 500mg QDS
OR
Erythromycin 500mg QDS

Question 6

Interpretation of Well’s score

Answer 6

If scoring 2+ points, DVT likely

If scoring <1 point, DVT unlikely

Question 7

Protocol if Well’s Score +ve

Answer 7

D-Dimer +ve, USS -ve = re-scan in a week

D-Dimer -ve, USS +ve = treat as DVT

D-Dimer -ve, USS -ve = DVT excluded

Question 8

Protocol if Well’s Score -ve

Answer 8

D-Dimer -ve = DVT excluded

D-Dimer +ve, USS -ve = DVT excluded

Question 9

Management of DVT?

Answer 9

LMWH/Heparin initially (as warfarin is pro-thrombotic for first 24 hours)
—>
Then switch to Warfarin, aiming for INR of 2-3
—>
Can make the switch for DOAC once established on warfarin

Discharge with adequate follow-up. Warn to come back immediately if SoB

Question 10

Rules for stopping COCP and surgery

Answer 10

Stop COCP 4 weeks pre-op, and dont start again until 2 weeks post op
Mobilise early
Prophylactic LMWH if high risk group

Question 11

Pathophysiology of gout?

Answer 11

Monosodium urate crystals in joints
Due to..
Under-excretion by kidneys (age, CKD, HTN)
Over production - dietary - alcohol excess, purine rich meats

Question 12

Management of Gout?

Answer 12

High dose NSAID + PPI cover

Allopurinol - but not during acute attack as initial therapy may worsen
Wait 3 weeks after then start - takes a long time to lower urate levels

ALT - Febuxostat, dietary modification

Question 13

Clinical features of septic arthritis

Answer 13

Knee affected in 50% of cases. Joint destruction may occur in <24 hrs
Common organism - Staph A

Red, hot, swollen joint + systemically unwell

Question 14

Investigations in septic arthritis

Answer 14

X-ray/CT may be of little use

Urgent synovial fluid aspiration + culture

Question 15

Management of septic arthritis?

Answer 15

Flucloxacillin, 2g, QDS - IV - for 2 WEEKS
ALT - vancomycin + cefuroxime/cefotaxime

THEN.. Oral switch for further 2-4 weeks