Pt w/ atraumatic leg pain

Question 1

What are the 6Ps of acute limb ischaemia?

What makes these symptoms worse?

Answer 1

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

Question 2

What are the leading causes of acute limb ischaemia IN TRAUMA?

Answer 2

Compartment syndrome and crush injuries

Question 3

What are the leading causes of acute limb ischaemia in the absence of trauma?

Answer 3

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

Question 4

What are some risk factors for acute limb ischaemia?

Answer 4

Smoking, HTN, diabetes and hypercholesterolaemia

Question 5

Investigations for acute limb ischaemia

Answer 5

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

Question 6

Management of acute limb ischaemia

Answer 6

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

Question 7

Presenting features of cellulitis

Answer 7

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

Question 8

What is the most common causative organism of cellulitis and what increases the chance of infection?

Answer 8

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

Question 9

Investigations for cellulitis

Answer 9

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

Question 10

Management of cellulitis

Answer 10

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

Question 11

Presentation of DVT

Answer 11

Pain, swelling, redness, thrombophlebitis, tenderness, warmth, dilated superficial vessels

UNILATERAL

Question 12

Causes and risk factors of DVT:

Answer 12

Immobility, recent surgery or limb injury 
Active malignancy or recent 
Pregnancy 
Long haul flight 
COCP
IVDU 
Personal or family history of DVT

Question 13

Relevant investigations for DVT

Answer 13

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

Question 14

Management for DVT

Answer 14

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)

Question 15

Presentation of gout

Answer 15

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

Question 16

Causes of gout

Answer 16

Due to URATE CRYSTALS precipitating in the joint space.
RF:
- Diet high in purines 
- Diuretics 
- Trauma 
- Renal failure 
- Alcohol excess
- Leukaemia

Question 17

Investigations for gout

Answer 17

Examine the joint and aspirate it (looking for tophi and bifringent crystals)
XRAY might show punched out lesson in the articular surfaces

Question 18

Management for gout

Answer 18

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)

Question 19

What should always be a differential diagnosis in gout

Answer 19

Septic arthritis (MONOARHTOPATHY)

Question 20

Clinical presentation of septic arthritis

Answer 20

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

Question 21

What are some causes of septic arthritis?

Answer 21

Spontaneous
Recent overlying trauma or surgery in the area
IVDU - HAEMATOGENOUS SPREAD

Question 22

What organisms commonly cause septic arthritis?

Answer 22

Staph aureus, Gonococcus, Strep, TB, Salmonella, Haemophilus

Question 23

What investigations should you do for suspected septic arthritis?

Answer 23

FBC, U&E, CRP, ESR, Blood cultures (infection can easily enter the blood stream if this wasn’t the initial source)
Joint aspiration

Question 24

What is the management of septic arthritis?

Answer 24

IV FLUCLOXACILLIN AND BENZYLPENICILLIN

Refer urgently to the orthopaedic team for drainage and lavage of joint