Painful swollen leg Flashcards
DDx of Unilateral calf swelling
- Deep ven thrombosis (DVT)
- Cellulitis
- Ruptured Baker’s cyst
- Muscular strain (e.g. torn gastrocnemius)
- Allergic response
- Septic artritis (e.g. by insect bite)
- Compartment syndrome
DDx of Bilateral calf swelling
- Right heart failure (in isolation or together with LHF)
- Lymphoedema
- Venous insufficiency
- Pregnancy
- Vasodilators (e.g. CCBs)
- Hypoalbuminaemia
* Renal failure, liver failure, malabsorption, sepsis - Pelvic tumour (e.g. ovarian) compressing the inferior vena cava
- Fluid overload (iatrogenic)
History for unilateral calf swelling
- Pain - SOCRATES (name out)
- Periods of immobility (long travel, recent surgery)
- PMHx - Hx of DVT/PE, past or active cancers
- Systemic symptoms - feeling hot/cold, chest pain, SOB
- FHx of DVT or other thrombotic tendencies
What would you be looking for O/E to help with your differential?
I would look for clinical signs of a DVT including:
1. Tenderness and firmness of the calf on palpation
2. Calf pain on dorsiflexion - Homans sign
3. Discolouration of the peripheral foot
4. Swelling of the affected leg (would measure against contralateral leg)
5. Spreading erythema, trauma, breakdown of the skin may indicate cellulitis
I would also check for palpable peripheral pulses, capillary refill time distally and temperature of the foot compared to the other site to r/o ischaemic pain of the foot
What investigations would you arrange?
My assessment will dictate how I investigate the patient. I would first do a full history and examination, with a full set of observations
If suspecting cellulitis:
* Blood tests looking for evidence of infection and inflammation
If suspecting DVT:
* Calculate the modified Well’s criteria
* Based on ^^, send a D-dimer if the pre-test probability of DVT is low
* U&Es (renal function important for anticoagulation, contrast)
If likelihood of DVT high > arrange an urgent ultrasound Doppler to r/o DVT
If suspecting an acute bony injury > X-RAY
What is the benefit of the Well’s criteria?
The Well’s criteria for DVT is a score that predicts the likelihood of DVT
It’s a clinical aid rather than for management
Allows physicians to make a decision on blood testing with D-Dimer against US doppler (more expensive and more difficult to arrange)
If low pre-test probability > D-Dimer
If high pre-test probability > Doppler
Cut-off is 2
Specificity of 90%, sensitivity of 67%
You work out the Well’s score to be 4. How would you investigate this specific patient?
Higher likelihood of DVT
1. Arrange ultrasound Doppler of the leg
2. Acc to NICE - should happen within 4 hours before decision made on treatment
3. If it cannot be completed within 4 hours, I would send a D-dimer and start anticoagulation whilst an ultrasound is awaited. Ultrasound Doppler should than happen within **24 hours **of a suspected DVT being diagnosed
You arrange an ultrasound scan which shows Mrs Jacobs has a DVT. How would you treat her?
I would start Mrs Jacobs on anticoagulation
As per NICE
* Newly diagnosed pts with DVT should be started on either apixaban or rivaroxaban or LMWH
But would also consult local policy on which agent to start
- DOAC can be started immediately (after pt counselling) without bridging with LMWH (unlike Warfarin)
If DOACs not available or suitable, I would start LMWH whilst awaiting advice from a senior colleague
I would refer her to the local anticoagulation clinic to carry on the treatment
What is the length of DVT anticoagulation treatment?
The length of anticogulation treatment of DVT is dependent on the cause of the DVT
Clear cause for the DVT
* 3 months
DVT caused by cancer, proximal DVTs or unprovoked DVT
* Longer
How would you counsel someone before starting anticoagulation?
Patients should be given both verbal and written information on
* how to use the type of anticoagulation
* the duration of treatment
* possible side effects and how to manage these
* the effects of other medications and OTC meds on their effects
* Informing them that they should discuss its use with medical professionals before planned procedures or becoming pregnant
Patients should be provided with an anticoagulation booklet and ALERT card that they should keep on their person at all times
What further investigations may be helpful for an unprovoked DVT?
Pts with unprovoked DVT not known to have cancer
* Review their medical Hx, baseline blood tests (FBC, renal and hepatic function, PT and APTT)
* Should be physically examined
CT-CAP not routinely ordered for pts with unprovoked DVT unless there is a clinical indication for this test (a change from NICE 2020)
Thrombophilia testing should not be routinely offeredbut may be considered in pts with unprovoked DVT, if there is a plan to stop long term anticoagulation
Mrs Jacobs mentions she has been experiencing some bloating for several months. O/E - abdominal mass. After discussion with your consultant, you arrange a CT scan, which finds evidence of probable ovarian cancer. Mrs Jacobs would like to know the result. What is important to consider when breaking bad news?
Start with an introduction
* Reiterate case details you already know and check her understanding
* Begin with info gathering: “How have you been feeling since we last spoke?”
Deliver a warning shot:
* “I’m afraid we have found something on the scan”
Pause
* Allow Mrs Jacobs time to process the information
Explain clearly but concisely:
* “The scan has shown a finding that suggests that there may be cancer. At this stage, it is only a possibility, and further assessment will be needed”
Avoid speculation on outcomes:
* Politely say: “I don’t know exactly what this means yet. I will speak with my consultant and refer you urgently to the cancer team”.
Provide reassurance about next steps
* “You will be seen by the specialist team within two weeks, and they will guide you through the next steps”
End with empathy and safety net:
* I can only imagine how upsetting this may be. Is there anything you would like to ask me before we finish?
* If you feel unwell or have any concers, please contact us immediately
Who could you speak to, to help you with breaking bad news?
Registrar/consultant about delivering bad news - extremely difficult sitations might require them to attend the consultation to offer the patient support and me
Good idea to take a nurse specialist to join for consultation and will be great at helping the patient and me, particularly after the consultation
Also beneficial to have another member of staff (nurse / HCA) to help with consoling and providing empathy
Which of the following statements is true regarding DVTs and D-Dimers?
- D-dimer is always elevated if there is a DVT
- D-dimer is specific for DVT
- Elevated D-dimer is diagnostic of DVT
- Patients should be treated based upon D-dimer alone
- D-dimer is useful for excluding DVT if the pre-test probability (Wells) is low (<2)
5 - The use of D-dimer to exclude venous thromboembolism is only validated in combination with a clinical probability score (e.g. Wells, Geneva, or even the clinician’s ‘gestalt’ or impression).
Always calculate the pre-test probability, and if this is moderate or high, you will not be able to to rule out pathology with a negative D-dimer and should consider going directly to definitive imaging (e.g. Doppler ultrasound)
What is the target INR range in a patient with a proven DVT?
- a) 1-2
- b) 1.5-2.5
- c) 2-3
- d) 2.5-3.5
- e) 3-4
c) - The target INR range for patients presenting with a DVT is 2-3. Patients with arterial thromboembolism, or those who develop a DVT while already taking anticoagulatins, require a higher target range of 3-4
