4 patients with pains in their legs………………

Mr H

• 65 years of age• Type II Diabetes• Developed shortness of

breath when walking the dog

• Worse when he is climbing hills and better when he comes down

• Starts to develop pain in his right leg as well

Medication

• Ramipril

• Aspirin

• Atenolol

• Metformin

• Simvastatin

• What are the main pathologies here?• Which symptoms need to asked when enquiring

about his leg pain?

• Can you explain the indications for each of the medications that are listed

• Name 3 side effects of each one

• What is the most likely cause of this mans leg pain?

• What else can cause similar pain and how do you distinguish this?

Assessment

• How would you assess this patient on clinical examination?

• Which features in the history or examination would support your diagnosis

• He is referred to hospital – which investigations might help

Management

• What are the priorities for this man’s management?

• What would you advise relating to his medication?

• Which factors need to be taken into account relating to managing this man?

MR G

• Aged 72

• Presents with aching pain in right thigh

• Pain also felt in right groin and into his knee

• Pain worse when he walks but also keeping him awake at night

Examination

• What sort of assessment would you make in this man when examining him?

• Can you explain /demonstrate the examination process to your colleagues?

• What sort of tests might help you and why might you be doing them?

Test results

• X ray hip – suggests early arthritic change in right hip ( subchondral sclerosis, loss of joint space and a few osteophytes)

• Full blood count normal

• ESR 100

• Alkaline Phosphatase raised but ALT normal

• What does the x ray report suggest?

• What are the causes of a high ESR?

• What might cause the raised ALP?

• What else might be going on here and how would you follow this up?

Mr K

• 55 fork lift truck driver

• Long history of low back pain

• Develops pain in low back which is causing early morning stiffness

• Bends down to clip toe nails and develops sudden severe pain in the leg on the left

Clinical assessment

• What is the most likely pathology here?

• How would you examine and assess this man clinically?

• Can you demonstrate the examination to you colleagues?

• What questions do you need to particularly need to ask this man ?

Tests

• Normal FBC but slightly raised ESR at 40 and CRP at 12

• X ray – Radiologists decline to perform plain film – is this correct?

• What can be seen on a plain film?

• What might be a more useful method of assessing this man?

http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow204arr.jpg

• What might you think if the patient is an 80 year old woman?

Red flags

• What symptoms in the history might suggest that there is something more going on?

• How can you make a reasonable assessment of this?

• What actions are open to the primary care doctor when assessing a patient with low back pain

Red flag" and "yellow flag" signs Red flags are possible indicators of

serious spinal pathology

• Thoracic pain • Fever and unexplained weight loss • Bladder or bowel dysfunction • History of carcinoma • Ill health or presence of other medical illness • Progressive neurological deficit • Disturbed gait, saddle anaesthesia • Age of onset <20 years or >55 years

Yellow flags are psychosocial factors shown to be indicative of long term

chronicity and disability

• A negative attitude that back pain is harmful or potentially severely disabling

• Fear avoidance behaviour and reduced activity levels

• An expectation that passive, rather than active, treatment will be beneficial

• A tendency to depression, low morale, and social withdrawal

• Social or financial problems

Mrs F

• Develops pain initially in one then both legs when walking

• Initially buttocks and thighs then spreads to feet

• Gets better when sits and leans forward

• She gets this when walking home at the same place each night

• Worse when she goes down hill

• Last three weeks also noted that her legs get weak when she walks too far

What does this picture suggest?

Which of the following tests would you request?

• Plain lateral x ray lumbar spine

• MRI scan?

• Bone scan?

Lumbar canal stenosis

• Narrowing canal or neural foramina

• Ischaemia of cord or cauda equina

• Usually combination disc problem, osteophytes and hypertrophy ligamentum flavum

• Commonest>60s

Can you think of conditions that might predispose to this problem?

Associated conditions

• Congenital narrowing of the spinal canal (much less common than degenerative).

• Degenerative - osteoarthritis. • Hyperparathyroidism. • Paget's disease. • Ankylosing spondylitis. • Cushing's syndrome. • Acromegaly.

Questions