Swollen calf

Question 1

What are the differential diagnoses for bilateral calf swelling?

Answer 1

> More likely to be systemic or central vessels
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Question 2

Specific system review/history taking questions to ask to assess risk of DVT?

Answer 2

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Ask about PE symptoms

• SOB
• Chest pain
• Coughing up blood

Question 3

Questions to ask to rule out septic arthritis for calf swelling?

Answer 3

• Does movement of joints elicit pain?- excruciating

- Any wounds?

Question 4

Questions to rule out cellulitis?

Answer 4

• Insect bite/wounds? (also consider allergic reaction to insect bite in this case)
• Is swelling getting rapidly bigger?

Question 5

Questions for bilateral swelling to rule out pelvic tumour?

Answer 5

• Abdominal pain?
• Blood in faeces?
• Unusual vaginal bleeding?
• Weight loss/fever/malaise?

Question 6

What do you look for on examination if you suspect DVT?

Answer 6

Inspection and palpation of calf:
- Cuts, bites, wounds or superficial infections
Also inspect toes for fungal infection entry route
- Warmth- calor
- Redness/erythema- rubor
- Swelling
o Pitting vs non pitting oedema
o Location of swelling
- If joint= septic arthritis
- If not joint, but thigh or calf= compartment syndrome
- If popliteal fossa down into calf= ruptured Baker’s cyst
o Extent of swelling
- use tape measure to see circumference of both limbs
- Mark swelling/erythema with pen to monitor progression

• Lymphadenopathy- palpate lymph nodes in popliteal fossa and groin- indicates infection

> Palpate abdomen- check for right/left lower quadrant masses that could compress iliac veins

> Neurovascular exam of limb
- Check sensation
- Check motor
- gentle passive movement - be v slow to avoid dislodging DVTs
- If pain in joint= septic arthritis
- If pain in calf= compartment syndrome
- movement against resistance
- Check pulse
^Distal to the swelling
If compromised- surgical emergency, could indicate compartment syndrome

• Check temperature- if pyrexic - more likely to be infection than DVT

Question 7

Which scoring system measures DVT risk?

Answer 7

(Modified) Wells

Question 8

What score on the Wells scoring system indicates likely risk of DVT?

Answer 8

> or equal to 2

Question 9

Investigations for DVT

Answer 9

• Do wells score

Then

• Serum D- dimer (fibrin degradation products)
  
  • If negative, used to exclude (not confirm) DVT if wells score is less than 2 (if more than 2, do D dimer and ultrasound to exclude)
• Doppler ultrasound scan
  
  • sensitive, rapid, non invasive + can also detect Baker’s cysts
• FBC
  
  • To look for:
    WBCs- cellulitis
    RBC- polycythaemia- can cause DVT
    Increased platelets- cancer - causing DVT
• Clotting factors

Question 10

Management of DVT- 3 key things?

Answer 10

o Anticoagulant
   - Subcutaneous low molecular weight heparin
   - Warfarin/DOAC
o Compression stockings
o Lifestyle advice
  - Lose weight
  - Move around/exercise on long haul travel
  - Stop oral contraceptive/HRT

Question 11

Short case: signs indicating compartment syndrome

Answer 11

• Absent sensation
• Absent pulses distal to swelling
• Tense, shiny, red, swollen
• Painful on passive movement (not on joints)

Question 12

What is compartment syndrome and what can it cause?

Answer 12

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-Volkmann’s contracture

Question 13

Management of allergic insect bite

Answer 13

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