Pt w/ atraumatic leg pain Flashcards
What are the 6Ps of acute limb ischaemia?
What makes these symptoms worse?
Pulseless Perishingly cold Paralysed Pale Parasthesia (tingling) Painful
these symptoms will be worse in someone who has had a previously normal limb - chronic arterial disease may make the onset more insidious
What are the leading causes of acute limb ischaemia IN TRAUMA?
Compartment syndrome and crush injuries
What are the leading causes of acute limb ischaemia in the absence of trauma?
Emboli / Thrombi
- AF
- Post MI
- Prosthetic valves
- Atrial myxoma (benign tumour of the heart)
- Vegetations
**always ask about other embolic/thrombotic events in the hx
What are some risk factors for acute limb ischaemia?
Smoking, HTN, diabetes and hypercholesterolaemia
Investigations for acute limb ischaemia
PHYSICAL EXAMINATION:
- Feel for temperature, palpate all pulses (dorsalis pedis, posterior tibialis and popliteal) - consider doppler if can’t find
- Look for sources of emboli (arrhythmias, murmurs, valve sounds etc.)
BLOODS: FBC, U&E, CK, Coag screen, ABG
ECG - arrhythmias
CXR
Urinalysis to check for myoglobin (this tells us about muscle damage)
Cardiac/abdo USS
Management of acute limb ischaemia
Pain relief - IV opioid is most likely as they are very painful
Correct hypovolaemia IV fluids
Revascularisation must happen within 6 hours to avoid permanent muscle damage/rhabdomyolysis/renal failure - EMBOLECTOMY / ANGIOGRAPHY
Presenting features of cellulitis
Red, hot, swollen, painful leg unilaterally
- might be a circumscribed area of redness or might be whole leg
- might be associated with some kind of trauma (break in skin) - but can be spontaneous
What is the most common causative organism of cellulitis and what increases the chance of infection?
Staph aureus (MRSA can cause) - also group A strep infection risk increased if foreign body remains in the wound, if there is a haemtoma or devitalised tissue or if there is compromised nutrition or immunity
Investigations for cellulitis
Often a clinical diagnosis but always examine the leg for the extent of rubor, tumour and dolor (consider marking it to track progress)
Take swabs of any wounds)
Really important to FEEL FOR PULSES and check the neurovascular system is in tact
BE AWARE OF SEPSIS
Management of cellulitis
CONSIDER ADMISSION IF:
- patient has fever >38, is systemically unwell, has regional lymphadenopathy or the cellulitis is extensive
ABX:
- FLUCLOXACILLIN or CLARITHROMYCIN (if penicillin allergic)
- Co-amoxiclav in facial cellulitis
MONITOR FOR SEPSIS
Presentation of DVT
Pain, swelling, redness, thrombophlebitis, tenderness, warmth, dilated superficial vessels
UNILATERAL
Causes and risk factors of DVT:
Immobility, recent surgery or limb injury Active malignancy or recent Pregnancy Long haul flight COCP IVDU Personal or family history of DVT
Relevant investigations for DVT
Thorough investigation of the limb
Measure the calf size (measure 10cm down from tibial tuberosity, if >3cm larger then confirmed swelling)
Calculate a WELL’S SCORE
FBC, U&E, CRP, glucose
Management for DVT
Monitor obs (PE risk)
Calculate their Well’s and this will tell you whether you should take a D-DIMER:
- if the Well’s score suggests the person is LOW RISK for DVT then take a D-Dimer (high risk then treat regardless)
- if Well’s is low and D-dimer is low rule out DVT
- If Well’s is low and D-dimer is high then does not confirm - continue considering other differentials
IF THEY ARE LIKELY - refer for proximal vein USS within 4hr
Then give LMWH depending on trust guidelines (dalteparin, enoxaparin or tinzaparin)
Presentation of gout
Mainly PAIN - usually in the first MTPJ (big toe) but can be anywhere (other common site is knee)
ATRAUMATIC PAIN OVER SINGLE JOINT WITH NO OTHER SYMPTOMS - consider gout
Follows a relapsing and remitting pattern so this might be a first presentation or it might be an acute exacerbation
Causes of gout
Due to URATE CRYSTALS precipitating in the joint space. RF: - Diet high in purines - Diuretics - Trauma - Renal failure - Alcohol excess - Leukaemia
Investigations for gout
Examine the joint and aspirate it (looking for tophi and bifringent crystals)
XRAY might show punched out lesson in the articular surfaces
Management for gout
DURING AN ACUTE EXACERBATION:
NSAIDS: Diclofenac 75mg BD works well
Oral steroids (30mg Pred OD)
Then maintenance therapy of allopurinol started my GP (not during acute phase)
What should always be a differential diagnosis in gout
Septic arthritis (MONOARHTOPATHY)
Clinical presentation of septic arthritis
Very painful joint (knee is common) usually won’t tolerate any movement or palpation
Pt might also have fevers, rigors and shaking and be systemically unwell
What are some causes of septic arthritis?
Spontaneous
Recent overlying trauma or surgery in the area
IVDU - HAEMATOGENOUS SPREAD
What organisms commonly cause septic arthritis?
Staph aureus, Gonococcus, Strep, TB, Salmonella, Haemophilus
What investigations should you do for suspected septic arthritis?
FBC, U&E, CRP, ESR, Blood cultures (infection can easily enter the blood stream if this wasn’t the initial source)
Joint aspiration
What is the management of septic arthritis?
IV FLUCLOXACILLIN AND BENZYLPENICILLIN
Refer urgently to the orthopaedic team for drainage and lavage of joint
