Case 7 - 57 yo with leg swelling Flashcards
Causes of mortality in the US
- Smoking
- Obesity
- Diabetes
- Hypertension
Known health risks of obesity
HTN, dyslipidemia, T2DM, CHD, strokem gallbladder dz, OA, OSA, endometrial, breast, colon cancer
Diabetic foot exam
- foot ulceration due to impaired sensation and impaired perfusion
- sensory testing with vibration and pinprick
- assess pedal pulses
- inspect for breaks in skin, pressure calluses, ulceration
Wagner ulcer grading system
Grade 1 - superficial involving full skin thickness
Grade 2 - deep penetrating to ligaments and muscle, no bone
Grace 3 - deep ulcer, with cellulitis or abscess formation
Grade 4 - localized gangrene
Grade 5 - extensive gangrene
Differential diagnosis for unilateral lower extremity swelling
- Cellulitis - diabetics more susceptible to cellulitis
- DVT - pe shows palpable cord of thrombosed vein, dull ache, swelling pain, discoloration
- Venous insufficiency - veins become rigid and thick-walled, erythema, statis dermatitis, hyperpigmentation, ulcerations on malleoli
- Lymphedema - generally painless swelling,
- Peripheral artery disease - claudication, night pain, non-healing ulcers, skin color changes
Less likley: muscle strain, popliteal cyst
Studies for unilateral lower extremity swelling
- doppler to evaluate for DVT
- d-dimer - poorly specific but relatively sensitive
- CBC for WBC
- lytes, glucose, renal fxn
- baseline coags
- A1C
Well’s criteria for diagnosis of DVT
One point for each:
- active cancer
- paralysis, paresis or recent plaster immobilization of legs
- recently bedridden for more than three days or major surgery
- localized tenderness
- entire leg swollen
- calf swelling by more than 3 cm
- pitting edema
- collateral superficial veins
3 points = high probability
1-2 points = moderate probability
<0 = low probability
Management of DVT
- goals are to prevent PE
- anticoagulate with LMWH (longer half life, can be administered subQ, no need for labs)
- warfarin - for prolonged prophylactic therapy, treatment duration varies based on history: isolated calf thrombophebitis: 6-12 weeks, 1st time event as results of trauma or surgery: 3 months, first episode idiopathic: 6 months, recurrent or inherited thrombophillia: 12 months to forever
Titrating warfarin
Half life is 40 hours, so takes 4-5 days to reach steady state
Check INR, if between 5-9 hold warfarin
If INR >9, hold warfarin and give oral vitamin K
Screening for inherited thrombophilia
screen those with initial thrombosis prior to age 50 without risk factor, fam hx, recent personal venous thrombosis, thrombosis occuring in unusual vascular beds
