Atraumatic leg pain

Question 1

Acute ischaemic leg: revascularisation required in what time frame to save the limb?

Answer 1

Within 4-6 hours!!

Question 2

3 most common causes of acute ischaemic leg (non-traumatic)

Answer 2

Embolus
Thrombus
Graft/angioplasty occlusion

Question 3

acute ischaemic leg: most common source of embolus

Answer 3

Cardiac - e.g. AF/ post-MI

Most common at artery bifurcations

Question 4

If thrombus is the cause of acute ischaemic leg, what is likely to be seen in the other limb?

Answer 4

History of PAD

Features of chronic vascular insufficiency in the other limb

Question 5

acute ischaemic leg:
Embolus presentation

How does the other leg appear?

Answer 5

Acute onset
Limb appears WHITE (no collateral circulation)

Other leg usually normal

Question 6

acute ischaemic leg: Thombus presentation

Why may symptoms be less severe than in embolus?

the other leg

Answer 6

More gradual onset

Collateral circulation usually ell-defined in people with PAD

Pulses in other leg may also be absent

Question 7

Investigations in suspected acutely ischaemic leg

Answer 7

CXR, ECG, USS

Bloods: FBC, Us+Es, CK, cross-match

Question 8

Signs of chronic vascular insufficiency

Answer 8

Muscle wasting, hair loss, arterial ulcers

Question 9

Buerger’s angle

Answer 9

Lift leg until foot goes pale (not the angle), hang off side of bed and watch recoloration - >15 seconds indicates severe ischaemia (may also go v red)

Question 10

Initial management of acute ischaemic limb (think A+E)

Answer 10

Analgesia - IV opioid
Correct any hypovolaemia
Contact vascular surgery!!

Question 11

Definitive management of acutely ischaemic limb

Answer 11

REVASCULARISATION!!

Question 12

In acute limb ischaemia, how can revascularisation be achieved?

What happens if the limb is unsalvegable

Answer 12

Endovascular (percutaneous catheter-directed thrombolysis)

Surgical (thromboembolectomy)

If unsalvegable, requires amputation

Question 13

Definitive management of PAD

Answer 13

Angioplasty/ bypass surgery (only after lifestyle advice + exerise programme)

Question 14

PAD: what can be given if patient does not want angioplasty/ bypass?

Answer 14

Naftidrofuryl oxalate

Question 15

What is gout?

Answer 15

Disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) & the deposition of urate crystals in joints & other tissues

Question 16

What is the role of xanthine oxidase in the body?

Answer 16

Metabolises xanthine (produced from purines) into uric acid

Question 17

In gout, why can’t urate be excreted properly? (2)

Answer 17

Either too much being made or kidneys can’t keep up with the demand

Question 18

What are the 3 phases of gout

Answer 18

Asymptomatic hyperuricaemia

Period of acute attacks (usually last 1-2 weeks), plus intervals with no symptoms

Chronic tophaceous gout

Question 19

Biggest RF for gout

Answer 19

HYPERURICAEMIA

usually due to impaired renal excretion of urate

Question 20

4 other RFs for gout

Answer 20

Inc age
Male
Alcohol
HTN

Question 21

What lifestyle advice would you give someone with gout?

Answer 21

Weight loss
Smoking cessation
Avoid purine-rich foods (e.g. red meat + anchovies)

Question 22

Which 2 joints are most commonly affected by gout?

Answer 22

1st MTP

Knee

Question 23

Presentation of gout

Answer 23

Sudden onset, severe joint pin

Red, hot + swollen joint

Question 24

Tophi
What are they?
When do they develop?
Where?
Are they painful?

Answer 24

Firm, white nodules under translucent skin

Usually develop after 10 years
Over extensors
Usually not painful

Question 25

In gout, when are serum uric acid levels measured?

Answer 25

4-6 weeks after an attack

Question 26

What PMH is important to ask about in suspected gout?

Answer 26

History of renal stones

Question 27

Management of a gout attack

Answer 27

NSAID or oral colchicine

Question 28

How long after a gout attack are NSAIDs continued for?

Answer 28

1-2 days

Question 29

Gout attack: alternative if NSAID not tolerated

Answer 29

Steroid

Question 30

Gout attack: adjunct pain relief

Answer 30

Paracetamol

Question 31

What is 1st line for urate-lowering therapy? What class of drug When should it be started?

Answer 31

Allopurinol Xanthine oxidase inhibitor Start AFTER acute attack has resolved

Question 32

What is the most common SE of allopurinol?

Answer 32

Rash

Question 33

2 most common causes of septic arthritis

Answer 33

Staph + strep

Question 34

Investigations in suspected septic arthritis

Answer 34

Bloods: FBC, ESR, CRP Blood cultures Arthrocentesis

Question 35

If suspected gonococcal arthritis, what other samples need to be taken?

Answer 35

Urethral, rectal + throat swabs

Question 36

Septic arthritis: when should IV abx be started?

Answer 36

After joint aspiration

Question 37

Septic arthritis: how long should abx be given for?

Answer 37

2 weeks IV PLUS 2 weeks oral

Question 38

Septic arthritis: abx for Staph A MRSA N gonorrhoea or gram neg bacilli

Answer 38

Staph A: fluclox MRSA: vancomycin N. gonorrhoea or gram neg bacilli: cefotaxime

Question 39

Management of severe Septic arthritis if joint isn't very accessible (e.g. hip)

Answer 39

Open washout