Week 3- Painful swollen leg

Question 1

76 year old woman who lives in Charters Towers presents to her GP. ‘I’ve got a cramp in my right leg and
it’s swollen since yesterday’.

Take a history from the 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

HPC:

• How long has the cramp been present
• Did it come on quickly/what were you doing?
• Character- tightness, pain- dull, sharp, burning
• Alleviating factors
• Have you experienced this before
• Radiation of the pain
• Associated symptoms- fever, bruising, erythema
• Effect on lifestyle

DVT; recent surgeries, recent long flights, past clots, family history of clots, any cancer, what medication do you take
MSK; any recent falls or trauma
Cellulitis; any redness, is the leg warm, recent cuts/abrasions to the leg

PMHx:

• Clotting disorders
• Prior PE/DVT
• Any malignancies
• Current mobility status
• Damage to lymphatics
• Lipid levels/diabetes

PSHx:
-Any past surgeries

Medications- any regular meds- OCP, clotting meds
Allergies- agent and reaction
Immunisations- fluvax, pneumoccocal

FHx:

• Family history of any clotting disorders
• Family history of any cancers

SHx:

• Background
• Occupation
• Education
• Religion
• Living arrangements ie. alone, assisted
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity- assess immobility

Systems:

• General; weight loss, fever, chills, night sweats
• CVS; palpitations, chest pain, orthopnea, PND
• RS: dyspnoea, cough, sputum, wheeze
• GI: vomiting, diarrhoea, constipation, abdo pain, dysphagia
• UG: dysuria, polyuria, nocturia, urgency, incontinence
• CNS: headaches, nausea, trouble with hearing/vision
• ENDO: heat/cold intolerance, swelling in neck/throat, polydipsia/polyuria
• HAEM: easy bruising, lumps in axilla/neck/groin
• MSK: painful or stiff joints, muscle aches, rash

Question 2

Perform an exam on the patient

Answer 2

General inspection:
-obvious pain/discomfort, dyspneic? stable?
Vital signs:
HR- tachy
RR- tachy
BP- hypotensive
Temp- febrile
Legs:
Inspection-> inspect with pt standing (oedema, swelling, skin changes, dilated/tortuous veins)
-Signs of venous insufficiency; venous eczema and haemosiderin deposits, lipodermatosclerosis, venous ulcers
Palpate-> temperature (in at least 3 places- feeling for heat), tenderness/pain (squeeze near ankle then up calves), pitting oedema (how high up does it go), peripheral pulses, measure leg diameters (measure 10cm below tibial tuberosity (less than 3cm diff not significant), homans sign (pain in calf when sharply dorsiflexed)
CVS/RS:
-JVP elevation
-Auscultation of heart and lung sounds

Question 3

What is the provisional and differential diagnosis

Answer 3

Provisional; DVT
DDX;
-PVD
-Cellulitis
-Venous insufficiency
-Malignancy

Question 4

What investigations would you order

Answer 4

FBC
U&E
LFT- coagulation studies
D-dimer
Duplex USS
To assess malignancy--> urine dipstick, abdo CT, CXR

Question 5

What treatment is required

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

What is the Wells Criteria for PE

Answer 6

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.

Question 7

What is the Wells Criteria for DVT

Answer 7

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.