Painful leg

Question 1

A 64-year-old man presents with pain in his right leg. His right dorsalis pedis and posterior tibial pulses are present. What are the possible causes and appropriate management of each cause?

Answer 1

Impression
Non-specific presentation, could represent a number of diagnoses including MSK pathology (fracture, muscle strain, compartment syndrome), vascular pathology (PVD, chronic limb ischaemia, DVT), rheumatological (arthropathy, etc), infective (cellulitis, necrotising fasciitis, etc)

Given the peripheral pulses are present, am more leaning towards a non-arterial cause of the presentation.

Question 2

Painful leg - History

Answer 2

History

• PC: SOCRATES, vascular sx (night pain, claudication, 6Ps), infective sx (fevers, wounds, etc), joint sx (joint pain, movement vs non-movement)
• REDFLAGS: acute limb ischaemia, DVT/PE, compartment syndrome
• NB: if pain significantly greater than signs, concern for either compartment syndrome or necrotising myositis
• HPI: timeline/acuity, treatments initiated
• PMHx: cardiovascular disease risk factors, HTN, diabetes, fam Hx
• SNAP

Question 3

Painful leg - Examination

Answer 3

Examination

• General obs + vital signs
• inspection of skin: temp, wounds,
• Peripheral vascular exam: pulses, painful, swelling, oedema
• LL neuro exam
• Knee + hip exam - referred pain
• Cardiorespiratory exam: bruits, AAA, PE

Question 4

Painful leg - Investigations

Answer 4

Investigations
- key/diagnostic: ABI, duplex ultrasound (vascular

• bedside: swabs + MCS, vitals,
• bloods: FBC, CRP/ESR, blood cultures, autoimmune panel
• Imaging: duplex US, knee/hip XR, CT angiography3

Question 5

Painful lef - management

Answer 5

Management

• cellulitis: empirical abx, fluids,
• DVT: anticoagulation
• PVD: vascular referral, diagnostic imaging (angiography),
• fractures: ortho consult