Week 3 - Leg cramp and swelling

Question 1

Mrs. Jenny A, 76 year old woman presents to her GP. ‘I’ve got a cramp in my right leg and it’s swollen since yesterday’.

Take a history of this patient.

HPC:
• Later age, pain comes on after supermarket shopping last night.
• Rubbing helps a bit. ‘Massage last night did not help’.
• Walking is really sore now. Pain worse, limping now.
• No trauma, no ‘Baker’s cyst’.
• Smoker 20/day. Importance? Risk factor for DVT
• F/H: Aunt died of clot in her lung 5 years ago - importance? Pulmonary embolism is complication of DVT. Therefore, family history (familial causes).
• On chemotherapy for breast cancer - importance? Cancer risk factor for DVT.
• No overseas travel, no fractures or immobility - importance? This history specifically relates to leg pain and DDx.
• No chest pain, HRT, SOB - importance?
• Left leg swollen, tender on palpation - Homan’s sign?

Answer 1

Age, gender, weight (i.e. obese)?

HPC:
• Site of swelling/pain? Unilateral or bilateral?
• When did it first start? 
• Character of pain?
• Does the pain radiate?
• Alleviating factors?
• Experienced it before?
• Exacerbating factors?
• Severity?
• Associated symptoms?
• Effect on lifestyle?

• Recent trauma/fracture?
• Recent immobilisation - long trip/overseas travel, bedridden?
• Recent sports injury?
• Skin changes?

PMHx:
• Past history of cardiovascular disease (e.g. CHF, MI, stroke), cancer, diabetes, hypertension?
• Previous DVT/PE?
• Obs/Gyn - multiple miscarriages? pregnant?
• Kidney problems (e.g. nephrotic syndrome)?

PSHx:
• Any recent surgeries?

Medications:
• OCP, HRT, chemotherapy (e.g. Tamoxifen)?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of blood clots/disorders, cancer?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs?
• Physical activity?

Systems Review:
• General - weight loss, fever?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough?
• GI - change in bowel habit?
• UG - breast lump?
• MSK - injuries, bony pain?
• CNS
• ENDO
• HAEM

Question 2

Perform a physical exam on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: stable, dyspnoea, pain/discomfort.
   DVT risks - cancer, pregnant, immobility (aids), signs of recent surgery, trauma, medications around bed.

3. Vital signs
• HR - tachycardic.
• RR - tachypnoeic.
• BP - hypotension.
• Temp - febrile.

4. Legs:
   • Inspection:
   - Inspect fully with patient standing - oedema/swelling, skin changes (colour - redness, cyanosis), dilated/tortuous superficial veins.
   - Venous insufficiency signs:
5. Venous eczema and haemosiderin deposits (red-brown patches).
6. Lipodermatosclerosis.
7. Venous ulcers.
   • Palpate:
   - Temperature (min. 3 places, increased warmth/heat).
   - Tenderness/pain (squeeze near ankle then up calves and observe face).
   - Pitting oedema (if present, how far does it extend?)
   - Check if pulses are present.
   - Measure leg diameters - measure circumference 10cm below tibial tuberosity (<3cm not significant).
   • Homan’s sign - pain in calf when the foot is sharply dorsiflexed.
8. CVS/RS:
   • JVP
   • Auscultation - heart sounds, lung bases (reduced sounds may be PE).

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: DVT
• DDx:
- PVD
- Varicose veins
- Cellulitis
- Malignancy

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC, U+Es, LFTs, coagulation studies.
• D-dimer.
• Duplex USS.

• If >40yo look for underlying malignancy: urine dipstick, FBC, U+Es, LFTs, CXR +/- CT abdo/pelvis.

Question 5

What treatment does this patient require?

Answer 5

• Anticoagulation therapy: initial anticoagulation is continued for 5-10 days. After that, long-term anticoagulation is continued for 3-12 months. The choice of anticoagulant depends upon multiple factors, including the preference of the patient and the healthcare provider, the patient’s medical history and other conditions, and cost considerations.

• Initial treatment - LMWH, Fondaparinux, unfractionated heparin or direct oral anticoagulants.
• Long-term - direct oral anticoagulants e.g. rivaroxaban, apixaban, dabigatran. If warfarin is used, INR must be measured on a regular basis to maintain the therapeutic range and lessen the likelihood of haemorrhage.

• Other options include:

• Thrombolytic therapy - reserved for patients who have serious complications related to PE or DVT, and who have a low risk of serious bleeding as a side effect of the therapy.
• IVC filters - recommended in patients with venous thromboembolism who cannot use anticoagulants because of a very high bleeding risk. However, in the long term, IVC filters can increase the risk of developing blood clots.

Question 6

Outline the Well’s criteria/score for DVT.

Answer 6

• Active cancer (treatment within last 6 months or palliative): +1 point.
• Bedridden recently > 3 days or major surgery in last 12 weeks: +1 point.
• Calf swelling > 3 cm compared to other leg (measured 10 cm below tibial tuberosity): +1 point.
• Collateral non-varicose superficial veins present: +1 point.
• Entire leg swollen: +1 point.
• Localised tenderness along the deep venous system: +1 point.
• Pitting oedema, confined to symptomatic leg: +1 point.
• Paralysis, paresis, or recent plaster immobilisation of leg: +1 point.
• Previously documented DVT: +1 point.
• Alternative diagnosis to DVT as likely or more likely: −2 points.

Risk of DVT
• Low: -2-0
• Moderate: 1-2
• High: 3-8

• DVT unlikely - ≤1
Perform D-dimer. If -ve, DVT excluded. If +ve, proceed to USS (if USS -ve, DVT excluded; if +ve, treat as DVT).

• DVT likely - ≥2
Do D-dimer and USS. If both -ve, DVT excluded. If USS +ve, treat as DVT. If D-dimer +ve and USS -ve, repeat USS in 1 week.

Question 7

Outline the Well’s criteria/score for PE.

Answer 7

• Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of deep veins): 3 points.
• Alternative diagnosis is less likely than PE: 3 points.
• Tachycardia (HR > 100): 1.5 points.
• Immobilisation at least 3 days or surgery in previous 4 weeks: 1.5 points.
• History of DVT or PE: 1.5 points.
• Haemoptysis: 1 point.
• Malignancy (with treatment within six months) or palliative: 1 point.

Total /12.5

Risk of PE (traditional interpretation):
• Low - <2
• Moderate - 2-6
• High - >6

Alternative interpretation:
• PE unlikely - ≤4. Consider D-dimer to rule out PE.
• PE likely - >4. Consider diagnostic imaging.