left leg pain brian lewis m.d. assistant professor of surgery medical college of wisconsin
TRANSCRIPT
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Left Leg Pain
Brian Lewis M.D.Assistant Professor of SurgeryMedical College of Wisconsin
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Ms. Doe
Ms. Doe is a 55-year-old woman, c/o progressive left leg pain. She is referred by her PMD to clinic today for evaluation of left leg pain. The right leg gives her no trouble.
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History
What other points of the history do you want to know?
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History, Ms. Doe Consider the following:
• Characterization of Symptoms:
• Temporal sequence• Alleviating /
Exacerbating factors:
• Associated signs/symptoms • Pertinent PMH• ROS• MEDS• Relevant Family Hx.• Relevant Social Hx.
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History, Ms. Doe
Characterization of symptoms• Pain occurs in left calf with walking, worsening over time.
Feels like a “cramp”. Limits her ability to play with her grandkids.
Temporal sequence• Only occurs with walking• Reproducible at the same distance
Alleviating / Exacerbating factors• Worse with walking especially up hill or stairs• Goes away when she stops
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History, Ms. Doe Associated signs/symptoms:
• No pain in foot when in bed, though both feet tend to be “numb”
• No wounds on feet
Pertinent PMH:• ROS: HTN, IDDM, Hyperlipidemia, no hx of DVT/clotting disorders
• MEDS: Insulin, Amitryptiline, Atorvostatin, Lisinopril, Neurontin
Relevant Family Hx.• Positive for CAD, Diabetes
Relevant Social Hx.• Smokes cigarettes ½ ppd for 40 years
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What is your Differential Diagnosis?
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Differential DiagnosisBased on History and Presentation
Muscle strain Dehydration Drug reaction – statins Tendonitis Deep venous thrombosis Claudication Arthritis Varicose veins Malignancy Sciatic nerve pain
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Physical Examination
What specifically would you look for?
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Physical Examination, Ms. Doe Vital Signs: T 98.6° F, P 82, BP 173/81, RR 16 Appearance: Healthy, pleasant, non distressed Relevant Exam findings for a problem focused assessment
HEENT: normal, no bruits Pulses: normal radial, femoral, carotid bilaterally; absent popliteal, DP and PT pulses bilaterally
Chest: clear bilaterally Neuromuscular: neuropathy in both feet
CV: RRR, no murmurs Skin/Soft Tissue: skin shiny on bilateral legs, no wounds, legs non-tender to palpation
Abd: Soft, nontender, no masses Remaining Examination findings Remaining Examination findings non-contributorynon-contributory
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Differential DiagnosisWould you like to update your differential?
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Studies (Labs, X-rays etc.)
What would you obtain?
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Studies, Ms. Doe
Ankle-brachial indices• Right:0.98• Left: Incompressible
Toe Pressures• Right: 60• Left: <20
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ABI
Can anyone describe how ankle brachial indices are performed?
What represents normal range? Abnormal? What conditions might falsely elevate the
number?
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Lab Studies ordered, Ms. Doe
CBC: Within normal limits
LFT’s Within normal limits
PT/PTT Within normal limits
Electrolytes Within normal limits
Urinalysis Within normal limits
Lipid Panel Within normal limits
Hb A1C 7.8
These were obtained by PMD 6 weeks ago
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Lab Results, Discussion
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Interventions at this point?
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How would you manage this patient?
Risk factor control− BP control− Lower lipids/cholesterol− Blood sugar control− Smoking cessation− β-blockers− ASA
Exercise program Medications
− Pentoxifylline− Cilostazol
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What next?
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Next Steps
How would you schedule follow-up? Any studies at time of follow-up?
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Ms. Doe calls the office 15 months later complaining of worsening symptoms in left leg.
Now pain when she walks only a few steps Now has an open wound on the left first toe
• States the wound has been present for weeks and is only getting worse
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Physical Examination
PE is unchanged with exception that there is a swollen left first toe with an open 1cm x 1cm necrotic based wound on the medial aspect
The toe is extremely tender There is no drainage from the wound
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What studies would you obtain?
Ankle-brachial indices• Right:0.98• Left: Incompressible
Toe Pressures• Right: 60• Left: <20
Anything else ?
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Angiogram
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Angiogram
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Angiogram
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Angiogram
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Angiogram
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Angiogram
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Angiogram
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Angiogram
How would you describe the findings?
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What would you do now?
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Management Options
Observe Surgery
• Options?• What workup would be required?
Endovascular management• Options?
What are some strengths and limitations of the various options?
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Post op Management
Discuss routine post op
Discuss most common complications
Mention any rare findings
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Discussion Additional teaching points
• Disease process− Claudication
• 1% - 2% of population <50 yo• Up to 5% of population 50 – 70 yo• Up to 10% greater then 70 yo• At 10 years only 25% have symptomatic disease
progression− Limb-threatening ischemia
• Develops in approximately 1 of every 100 claudicators• Obtaining consultants
− High incidence of CAD associated with PVD• Approximate percent with no or mild/mod CAD
40%• Approximate percent with advanced or severe CAD
60%
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QUESTIONS ??????
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Summary
Intervention for infra-inguinal vascular disease is most often reserved for ?• Rest pain• Tissue loss
Fix in-flow first Below the inguinal level vein is typically the preferred
conduit The role for endovascular management is evolving Vascular disease in a single territory is often a marker
for generalized vascular disease
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Acknowledgment The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials wewelcome your comments/ suggestions at: