Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in General Practice. Your next patient, Tom Hudson (61-year-old male) complaining of leg pain. Please take a history and carry out a relevant examination.
Patient History:
Tom Hudson, 61 y/o, recently retired – used to work as a business analyst.
You have been experiencing increasing leg pain for the past few days. The pain is located only at the left calf (only answer when specifically asked about the location). Pain is gradually getting worse and does not radiate to other parts of the body. Touching it makes it worse, and resting makes it better. The skin around the left calf feels hot and red; otherwise, no other skin changes. No previous injury towards calves.
There’s no coughing/ haemoptysis/ breathlessness. No fever/weight loss/ night sweats.
Ideas, Concerns, Expectations:
You think it might just be heart failure as you have been experiencing lower leg swelling for the past few years – which is why you are on furosemide. You can be concerned about the pain as there's limiting your rehab from your hip replacement which you had 1-2 weeks ago – you want to get better as soon as possible. You want to find out what is going on and have some painkillers.
Past Medical History:
Obesity, Diabetes Type 2, Hypertension, Heart Failure.
No previous malignancy with treatment within 6 months/ palliative.
No previous history of DVT/ PE.
Past Surgical History:
You just received a hip replacement 1-2 weeks ago, and due to pain, you have been quite immobile lately. Have been resting on a chair most of the time.
Drug History:
Metformin, Amlodipine, Multi-vitamins, Atorvastatin, Furosemide
Allergic to penicillin (anaphylactic reaction)
Family History:
Nil
Social History:
Do not smoke (used to smoke 10 cigarettes a day for 15 years)
Drink a beer every night with dinner
Live with wife
Retired - used to work as a business analyst.
Examination Findings:
Left calf erythema and warmth to touch
Distension of superficial veins and tenderness on palpitation of the left calf
Mild pitting oedema and swelling on both calves
The left calf swelling is worse than the right
Chest clear on auscultation
Differentials:
Deep Vein Thrombosis
Cellulitis
Superficial thrombophlebitis
Heart Failure
Trauma including calf muscle haematoma, calf muscle tear/ Achilles' tendon tear
Investigations:
Bedside:
Observations
ECG (sinus tachycardia / S1 Q3 T3 changes in PE)
Calculate Well's Score for DVT
Bloods:
Anticoagulation screen
Routine blood tests: FBC, Bone profile LFTs, U&Es, CRP (infections/renal function for scans and treatment)
Consider D-Dimer
Consider Antiphospholipid antibodies (if unprovoked)
Imaging:
USS scan (if Well’s score at least 2 points and is within 4 hours from onset)
CXR/ CT pulmonary angiogram (if suspecting pulmonary embolism)
Management: