One of the team has written a fantastic summary of differentials and points to consider in the history and examination: thanks olitodd1984! Please see his comments below:
Rule out infection– in the history ask about fevers, sweats, rigors, loss of appetite. On exam, look for rubor, callor, or dolor, erythema that tracks up the lymphatics, proximal lymphadenopathy, an entry point for bugs especially in the feet, particularly tinea pedis causing broken skin.
Worse, is there subcutaneous crepitus in keeping with necrotising fascitis, is the groin involved as in Fourier’s? This would need urgent surgical review.
Chronic venous or arterial insufficiency? Is there a history of earlier disease – was the onset gradual or very acute? Are there signs of chronic venous disease – lipodermatosclerosis, venous ulcers, varicositities, previous surgery? Arterial disease – cap refill, are dp and pt pulses present?
Could it be an arterial embolus? Pulses absent, pale cold distal limb?
Is there lymphatic obstruction? I would examine the abdomen, groin, and prostate/ rectum for an obstructing mass. Ask in the systems review about weight loss, change in bowel habits, and GU bleeding.
Are there risk factors for DVT– smoking,malignancy, immobility, coagulation disorder? Is the calf itself tender on compression? Are there clinical signs of PE– raised JVP? Right parasternal heave, tachypnoea?
FURTHER HISTORY AND RESULTS
Many of you were interested to know whether he had any systemic symptoms of concern. He does in fact complain of gastro-oesophageal reflux for which he takes (his wife’s) lansoprazole. He does not describe any bowel change, weight loss, chest symptoms or fatigue.
His Doppler USS confirmed the presence of a superficial femoral vein thrombosis. Bloods show:
Hb 119 g/l, MCV 81 fl,
LFTs = normal
CRP = 23
Coag = normal
Clinical examination did not suggest PE.
What anticoagulant would you choose? What influences you choice?
Does he need any further investigations? Why/why not?
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