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Flashcards in Swollen Calf Deck (32):
1

What are the main factors to consider when coming up with a differential diagnosis for calf swelling?

Is it acute or chronic?
Is it in one leg or both legs?

2

Construct a differential diagnosis for a single acutely swollen calf.

DVT
Cellulitis
Ruptured Baker’s cyst
Muscle strain
Septic arthritis
Allergic response (e.g. to an insect bite)
Compartment syndrome

3

Construct a differential diagnosis for bilateral calf swelling.

Right heart failure
Lymphoedema
Venous insufficiency
Pregnancy
Vasodilators (e.g. CCBs)
Hypoalbuminaemia
Pelvic tumour

4

List some key features of the history that you should ask the patient about.

Symptoms of PE
Cuts/wounds/insect bites on affected limb
Is the swelling getting any bigger?
Signs of pelvic malignancy (e.g. PR bleeding, unusual vaginal bleeding, abdominal pain)
Radiotherapy and surgery to affected leg

5

List some risk factors for DVT.

Trauma
Surgery
Bed rest
Long-haul travel
Cancer
Pregnancy
OCP and HRT

6

List the main symptoms of PE.

Breathlessness
Pleuritic chest pain
Haemoptysis

7

Which cause of calf swelling is associated with a rapidly growing swelling along the affected limb?

Cellulitis

8

Why should you ask about symptoms of GI, ovarian and uterine malignancy (e.g. PR bleeding, unusual vaginal bleeding, weight loss)?

A pelvic mass (e.g. a tumour) could compress the iliac veins or IVC leading to leg swelling

9

Why should you ask a patient about previous radiotherapy and surgery to the affected leg?

Increases risk of lymphedema

10

List how, on examination, the nature of the swelling is different in:
Septic Arthritis
Compartment Syndrome
Baker’s Cyst

- Septic Arthritis
Swelling around the joint
- Compartment Syndrome
Swelling/inflammation is confined to the compartment but spares the joints
- Baker’s Cyst
Swelling protrudes backwards from the knee joint into the popliteal fossa
NOTE: rupture of the Baker’s cyst can make the swelling run down into the calf

11

Why is it important to palpate for abdominal masses?

Abdominal masses could compress the IVC or iliac veins leading to leg swelling

12

Why is it important to assess the neurovascular status of the affected limb?

The high pressure within the compartment in compartment syndrome can lead to compromise of neurovascular status

13

Describe how the pain on passive movement is different in:
Septic Arthritis
Compartment Syndrome

- Septic Arthritis
Pain in the joint
- Compartment Syndrome
Pain in the calf

14

Describe how the Wells’ score is interpreted.

< 4 = D-dimer to rule out PE
4+ = CTPA

15

What the most sensitive, rapid and non-invasive method of visualising a DVT?

Doppler ultrasound of proximal leg veins
NOTE: this can also help distinguish DVTs from Baker’s cysts

16

Why might FBC and Clotting Screen be useful in a patient with a swollen calf?

FBC – may show high WCC (infection), high RBC (polycythaemia --> hypercoagulability)
Deranged coagulation – increased risk of clots forming

17

Outline the management of DVT.

Anticoagulation (with LMWH or fondaparinux, then ongoing anticoagulation is achieved with warfarin or rivaroxaban)
Compression stockings
Lifestyle advice (e.g. stop HRT/COCP, lose weight)

18

Describe the typical features of compartment syndrome.

Tense, shiny, swollen limb that is painful to passive movement

19

What is the most common cause of compartment syndrome?

Trauma

20

What can the high pressures within the compartment in compartment syndrome lead to?

Neurovascular compromise --> ischaemia and necrosis

21

What can compartment syndrome of the anterior compartment of the forearm lead to?

Volkmann’s contracture – permanent flexion of the wrist due to ischaemia and necrosis of the anterior forearm compartment muscles

22

How is acute compartment syndrome managed surgically?

Emergency fasciotomy

23

Outline the management of cellulitis.

Antibiotics
Demarcation of erythematous region to monitor progress
Elevation – helps reduce the swelling and reduce pain
Topical steroids and oral antihistamines – in the case of an inflammatory reaction to an insect bite (may present similarly to cellulitis)

24

What is a Baker’s cyst?

Swelling of a synovial bursa (usually the semimembranosus bursa) around the knee joint
NOTE: also known as a popliteal cyst

25

Rupture of a Baker’s cyst can be clinically indistinguishable from which other cause of calf swelling?

DVT

26

Outline the treatment of a ruptured Baker’s cyst.

Elevation of affected limb
Aspiration of fluid
Corticosteroid injection

27

List some congenital mutations that cause hypercoagulability.

Factor V leiden
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency

28

List some diseases that cause hypercoagulability.

Any malignancy
DIC
Antiphospholipid syndrome
Polycythaemia

29

List some drugs that cause hypercoagulability.

COCP
HRT
Procoagulant/antifibrinolytic drugs

30

Describe the mechanism of action of warfarin.

Vitamin K epoxide reductase inhibitor
Inhibits the gamma-carboxylation of factors 2, 7, 9 and 10
Also inhibits the production of protein C and protein S (thus causing an transient hypercoagulable stage)
This is why warfarin is started with LMWH until the INR has remained within the target range for > 24 hrs

31

List some contraindications for warfarin.

Pregnancy (teratogenic)
Severe hypertension (risk of haemorrhagic stroke)
Peptic ulcer disease

32

Under what circumstance can a DVT lead to a stroke rather than a PE?

Patent foramen ovale (PFO)