CARDIOPULMO - Leg pain

Question 1

Differential Diagnoses of Leg Pain

Answer 1

1. PVD*
2. PVD+cellulitis*
3. PVD+Ulcer
4. Chronic Venous ulcer
5. Cellulitis
6. DVT

Leg pain  
Probability diagnosis 
Muscle cramps
Nerve root ‘sciatica’
Varicose veins
Osteoarthritis (hip, knee)
Exercise-related pain (e.g. Achilles tendonitis), muscular injury (e.g. hamstring)

Serious disorders not to be missed  
Vascular:
•peripheral vascular disease 
•arterial occlusion (embolism)
•thrombosis popliteal aneurysm
•deep venous thrombosis
•iliofemoral thrombophlebitis

Neoplasia/cancer:
•primary (e.g. myeloma)
•metastases (e.g. breast to femur)

Infection:
•osteomyelitis
•septic arthritis
•erysipelas/cellulitis
•lymphangitis
•gas gangrene

Pitfalls (often missed) 
Osteoarthritis hip
Osgood–Schlatter disorder
Spinal canal stenosis → neurogenic claudication
Herpes zoster (early)
Greater trochanteric pain syndrome
Nerve entrapment (e.g. meralgia paraesthetica)
‘Hip pocket nerve’

Iatrogenic: injection into nerve
Sacroiliac disorders
Complex regional pain syndrome I
Peripheral neuropathy

Rarities:
•osteoid osteoma
•polymyalgia rheumatica (isolated)
•Paget disease
•popliteal artery entrapment
•tabes dorsalis
•ruptured Baker cyst

Masquerades checklist 
Depression
Diabetes
Drugs (indirect)
Anaemia (indirect)
spinal dysfunction 

Is the patient trying to tell me something?
Quite possible. Common with work-related injuries

Question 2

Leg Pain - Key History

Answer 2

Key history Ask:
•Is the pain acute or chronic onset?
•Did it follow trauma or activity?
•Is it ‘mechanical’ (related to movement)?
•Is it postural?
•Is it related to walking?
•Is the pain arising from bone or from a joint?
Past history, especially cardiovascular, back pain, trauma history

Question 3

Leg Pain - Key PE

Answer 3

Key examination

• Watch the patient walk and assess the nature of any limp. Note the posture of the back and examine the lumbar spine. Have both legs well exposed for inspection
• Palpate for local causes of pain and if no cause is evident examine the spine, blood vessels and bone. Note the temperature of the feet and legs
• Perform a vascular examination including the peripheral pulses and veins
• Consider a neurological examination to test nerve root lesions or entrapment neuropathies
• Examine the joints, especially the hip and sacroiliac joints

Question 4

Leg Pain - Key investigations

Answer 4

Key investigations
Consider:
•FBE and ESR
•radiology: plain X-ray, knee, hip, lumbosacral spine; CT or MRI, bone scan
•electromyography
•vascular studies: arterial tree or venous system

Question 5

Leg Pain - Diagnostic tips

Answer 5

Diagnostic tips

• Pain that does not fluctuate in intensity with movement, activity or posture has an inflammatory or neoplastic cause.
• Varicose veins can cause aching pain in the leg.
• Older people may present with claudication in the leg from spinal canal stenosis or arterial obstruction or both.
• Think of the hip pocket wallet as a cause of sciatica from the buttocks down.

Question 6

PVD - Management

Answer 6

Investigations
FBE, U/E/C, lipid profile, ECG, Doppler USG of lower limb to locate level of obstruction

• LSM - SNAP
• Refer to dietician
• Stop smoking - quit line - set another appointment
• Exercise - tolerable distance
• Check meds - stop beta blockers
• Start on aspirin and statin
• Refer to Specialist
• Regarding the obstruction, after doing lifestyle modification and you are still having pain, there are some surgical options
  o Stenting
  o Bypass grafting
  o Mesh wire
  Severe cases where untreatable ulcers/gangrene develops, sometimes amputations are required. I will refer you to the surgeon who will decide on surgical intervention. Usual indications are: pain at rest, atrophic skin changes, if pain interferes with patient’s life

Critical:

• Stop beta-blocker
• ABI