Left Leg Pain
Brian Lewis M.D.Assistant Professor of SurgeryMedical College of Wisconsin
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.
History
What other points of the history do you want to know?
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.
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
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
What is your Differential Diagnosis?
Differential DiagnosisBased on History and Presentation
Muscle strain Dehydration Drug reaction – statins Tendonitis Deep venous thrombosis Claudication Arthritis Varicose veins Malignancy Sciatic nerve pain
Physical Examination
What specifically would you look for?
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
Differential DiagnosisWould you like to update your differential?
Studies (Labs, X-rays etc.)
What would you obtain?
Studies, Ms. Doe
Ankle-brachial indices• Right:0.98• Left: Incompressible
Toe Pressures• Right: 60• Left: <20
ABI
Can anyone describe how ankle brachial indices are performed?
What represents normal range? Abnormal? What conditions might falsely elevate the
number?
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
Lab Results, Discussion
Interventions at this point?
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
What next?
Next Steps
How would you schedule follow-up? Any studies at time of follow-up?
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
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
What studies would you obtain?
Ankle-brachial indices• Right:0.98• Left: Incompressible
Toe Pressures• Right: 60• Left: <20
Anything else ?
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
Angiogram
How would you describe the findings?
What would you do now?
Management Options
Observe Surgery
• Options?• What workup would be required?
Endovascular management• Options?
What are some strengths and limitations of the various options?
Post op Management
Discuss routine post op
Discuss most common complications
Mention any rare findings
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%
QUESTIONS ??????
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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