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Left Leg Pain

Left Leg Pain. Brian Lewis M.D. Assistant Professor of Surgery Medical 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.

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Left Leg Pain

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  1. Left Leg Pain Brian Lewis M.D. Assistant Professor of Surgery Medical College of Wisconsin

  2. 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.

  3. History What other points of the history do you want to know?

  4. Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors: Associated signs/symptoms Pertinent PMH ROS MEDS Relevant Family Hx. Relevant Social Hx. History, Ms. DoeConsider the following:

  5. 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

  6. 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

  7. What is your Differential Diagnosis?

  8. Differential DiagnosisBased on History and Presentation • Muscle strain • Dehydration • Drug reaction – statins • Tendonitis • Deep venous thrombosis • Claudication • Arthritis • Varicose veins • Malignancy • Sciatic nerve pain

  9. Physical Examination What specifically would you look for?

  10. 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

  11. Differential DiagnosisWould you like to update your differential?

  12. Studies (Labs, X-rays etc.) What would you obtain?

  13. Studies, Ms. Doe • Ankle-brachial indices • Right: 0.98 • Left: Incompressible • Toe Pressures • Right: 60 • Left: <20

  14. ABI • Can anyone describe how ankle brachial indices are performed? • What represents normal range? Abnormal? • What conditions might falsely elevate the number?

  15. Lab Studies ordered, Ms. Doe These were obtained by PMD 6 weeks ago

  16. Lab Results, Discussion

  17. Interventions at this point?

  18. 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

  19. What next?

  20. Next Steps • How would you schedule follow-up? • Any studies at time of follow-up?

  21. 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

  22. 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

  23. What studies would you obtain? • Ankle-brachial indices • Right: 0.98 • Left: Incompressible • Toe Pressures • Right: 60 • Left: <20 Anything else ?

  24. Angiogram

  25. Angiogram

  26. Angiogram

  27. Angiogram

  28. Angiogram

  29. Angiogram

  30. Angiogram

  31. Angiogram • How would you describe the findings?

  32. What would you do now?

  33. Management Options • Observe • Surgery • Options? • What workup would be required? • Endovascular management • Options? • What are some strengths and limitations of the various options?

  34. Post op Management • Discuss routine post op • Discuss most common complications • Mention any rare findings

  35. 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%

  36. QUESTIONS ??????

  37. 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

  38. Acknowledgment The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials wewelcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

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