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Yr 3 Oxford Clinical Cases > Swollen Calf > Flashcards

Swollen Calf Flashcards

1
Q

What are the main factors to consider when coming up with a differential diagnosis for calf swelling?

A

Is it acute or chronic?

Is it in one leg or both legs?

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2
Q

Construct a differential diagnosis for a single acutely swollen calf.

A 
DVT 
Cellulitis 
Ruptured Baker’s cyst 
Muscle strain 
Septic arthritis 
Allergic response (e.g. to an insect bite) 
Compartment syndrome
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3
Q

Construct a differential diagnosis for bilateral calf swelling.

A 
Right heart failure 
Lymphoedema 
Venous insufficiency
Pregnancy
Vasodilators (e.g. CCBs)
Hypoalbuminaemia
Pelvic tumour
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4
Q

List some key features of the history that you should ask the patient about.

A

Symptoms of PE
Cuts/wounds/insect bites on affected limb
Is the swelling getting any bigger?
Signs of pelvic malignancy (e.g. PR bleeding, unusual vaginal bleeding, abdominal pain)
Radiotherapy and surgery to affected leg

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5
Q

List some risk factors for DVT.

A 
Trauma 
Surgery
Bed rest
Long-haul travel
Cancer
Pregnancy
OCP and HRT
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6
Q

List the main symptoms of PE.

A

Breathlessness
Pleuritic chest pain
Haemoptysis

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7
Q

Which cause of calf swelling is associated with a rapidly growing swelling along the affected limb?

A

Cellulitis

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8
Q

Why should you ask about symptoms of GI, ovarian and uterine malignancy (e.g. PR bleeding, unusual vaginal bleeding, weight loss)?

A

A pelvic mass (e.g. a tumour) could compress the iliac veins or IVC leading to leg swelling

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9
Q

Why should you ask a patient about previous radiotherapy and surgery to the affected leg?

A

Increases risk of lymphedema

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10
Q

List how, on examination, the nature of the swelling is different in:
Septic Arthritis
Compartment Syndrome
Baker’s Cyst

A
  • Septic Arthritis
    Swelling around the joint
  • Compartment Syndrome
    Swelling/inflammation is confined to the compartment but spares the joints
  • Baker’s Cyst
    Swelling protrudes backwards from the knee joint into the popliteal fossa
    NOTE: rupture of the Baker’s cyst can make the swelling run down into the calf
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11
Q

Why is it important to palpate for abdominal masses?

A

Abdominal masses could compress the IVC or iliac veins leading to leg swelling

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12
Q

Why is it important to assess the neurovascular status of the affected limb?

A

The high pressure within the compartment in compartment syndrome can lead to compromise of neurovascular status

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13
Q

Describe how the pain on passive movement is different in:
Septic Arthritis
Compartment Syndrome

A
  • Septic Arthritis
    Pain in the joint
  • Compartment Syndrome
    Pain in the calf
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14
Q

Describe how the Wells’ score is interpreted.

A

< 4 = D-dimer to rule out PE
4+ = CTPA
>2 + any D-dimer: DVT likely do Doppler USS
<2 & -ve D-Dimer: no USS needed

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15
Q

What the most sensitive, rapid and non-invasive method of visualising a DVT?

A

Doppler ultrasound of proximal leg veins

NOTE: this can also help distinguish DVTs from Baker’s cysts

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16
Q

Why might FBC and Clotting Screen be useful in a patient with a swollen calf?

A

FBC – may show high WCC (infection), high RBC (polycythaemia –> hypercoagulability)
Deranged coagulation – increased risk of clots forming

17
Q

Outline the management of DVT.

A 
Anticoagulation (with LMWH or fondaparinux, then ongoing anticoagulation is achieved with warfarin or rivaroxaban)
Compression stockings 
Lifestyle advice (e.g. stop HRT/COCP, lose weight)
18
Q

Describe the typical features of compartment syndrome.

What are the 5Ps?

A

Tense, shiny, swollen limb that is painful to passive movement
Pain, Paraesthesia, Paralysis, Pallor, Pulseless

19
Q

What is the most common cause of compartment syndrome?

A

Trauma

20
Q

What can the high pressures within the compartment in compartment syndrome lead to?

A

Neurovascular compromise –> ischaemia and necrosis

  • reduced sensation
  • absent pulses
21
Q

What can compartment syndrome of the anterior compartment of the forearm lead to?

A

Volkmann’s contracture – permanent flexion of the wrist due to ischaemia and necrosis of the anterior forearm compartment muscles

22
Q

How is acute compartment syndrome managed surgically?

A

Emergency fasciotomy

23
Q

Outline the management of cellulitis.

A

Antibiotics
Demarcation of erythematous region to monitor progress
Elevation – helps reduce the swelling and reduce pain
Topical steroids and oral antihistamines – in the case of an inflammatory reaction to an insect bite (may present similarly to cellulitis)

24
Q

What is a Baker’s cyst?

A

Swelling of a synovial bursa (usually the semimembranosus bursa) around the knee joint
NOTE: also known as a popliteal cyst

25
Q

Rupture of a Baker’s cyst can be clinically indistinguishable from which other cause of calf swelling?

A

DVT

26
Q

Outline the treatment of a ruptured Baker’s cyst.

A

Elevation of affected limb
Aspiration of fluid
Corticosteroid injection

27
Q

List some congenital mutations that cause hypercoagulability.

A

Factor V leiden
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency

28
Q

List some diseases that cause hypercoagulability.

A

Any malignancy
DIC
Antiphospholipid syndrome
Polycythaemia

29
Q

List some drugs that cause hypercoagulability.

A

COCP
HRT
Procoagulant/antifibrinolytic drugs

30
Q

Describe the mechanism of action of warfarin.

A

Vitamin K epoxide reductase inhibitor
Inhibits the gamma-carboxylation of factors 2, 7, 9 and 10
Also inhibits the production of protein C and protein S (thus causing an transient hypercoagulable stage)
This is why warfarin is started with LMWH until the INR has remained within the target range for > 24 hrs

31
Q

List some contraindications for warfarin.

A

Pregnancy (teratogenic)
Severe hypertension (risk of haemorrhagic stroke)
Peptic ulcer disease

32
Q

Under what circumstance can a DVT lead to a stroke rather than a PE?

A

Patent foramen ovale (PFO)

33
Q

List some contraindications for taking warfarin

A
  • Pregnancy (teratogenic)
  • Severe hypertension (risk of haemorrhagic stroke)
  • PUD (risk of bleeding)
34
Q

A patient suffers from DVT which keeps throwing off clots and causes small PEs. Shes already on LMWH and Warfarin what further tx can she be offered?

A

Place an IVC filter using a venous catheter to catch dislodged clots

35
Q

Which INR range should you aim for when treating someone with an uncomplicated DVT?

A

INR 2.0-3.0

Yr 3 Oxford Clinical Cases (28 decks)

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