Case 7:

53-year-old male with

unilateral leg swelling
By Parija Sharedalal

History
CC: Pt. is a 53-year-old male with a chief complaint
of swelling and pain in his left lower extremity."
PMH: Type 2 diabetes, hypertension, and
hyperlipidemia, obesity.
Social Hx: Does not drink alcohol, but does smoke
1.5 packs of cigarettes daily; unmarried, and lives
in public housing with his three children and one
grandchild.
ROS: No fever or chills, no chest pain,no shortness of
breath, and no swelling of the right leg.

In His words
When you ask the pt what
brings him in: , "It's my left
leg. The past four days it has
been red, swelling, and painful
-- and it seems to be getting
worse.", "It began several
days ago, and the swelling
seems to be getting worse. It
hurts all the time; it doesn't
even get better when I rest
it.It seems to get a little worse
when I move around.It hurts
to walk as soon as I try to
stand on it."

"Did you do anything to injure your foot?"

He replies, "I do not remember anyinjury, butthere has been this
soreon the bottom of my foot for several months.There's nothing
draining out of the sore and it doesn'thurt, althoughmy foot doesn't
have much feeling in it."
"Before this happened, where you were sitting down for a long time wit
hout getting up and using your legs, such as taking a long airplane tr
ip; or have you been on bed rest?"
"I wish could go somewhere on an airplane and get a good vacation,
but I can't afford anything like that. I haven't been on bed rest or
anything like that. I've been pretty busy lately."
"When was the last time you were in the office?"
"It has been a long time now becausemy daughter and new baby
recently moved in withme andI have been trying to take care of the
baby as well as keep myjob as a bus driver," he explains.
"Have you been taking your medication?"
He replies, "I have been out of my medication for several weeks now."

Physical Exam

Summary and
Differentials
Mr. Smith is a 53-year-old man with obesity, type 2
diabetes, hypertension, hyperlipidemia, and tobacco
use who presents with a four day history of left lower
extremity edema. He denies fever, chest pain,
dyspnea, known malignancy, trauma, or period of
inactivity. There is an ulcer on the plantar surface of
his left foot and edema and erythema involving the
entire left leg.

Differentials: Cellulitis, DVT

Best diagnostic test to differentiate: Venous
Doppler.

Cellulitis
Acute Inflammation characterized by erythema,
swelling, heat, pain.
Diabetics are more susceptible since diabetic
neuropathy causes insensitivity to abnormal
pressure distribution, ill-fitting shoes, cuts or
punctures which then develop into ulcers.
Lack of fever does not r/o cellulitis but a
presence of fever would support it.

DVT
Acute swelling, pain, discoloration in the
affected extremity.
Pts. usually complain of a dull ache in the leg
that worsens with prolonged standing and
resolves w/ leg elevation.
Homans Sign: Pain of passive dorsiflexion of
the foot.
Edema, tenderness, warmth
Risk factors: smoking, obesity, diabetes,
sedentary lifestyle, HTN, hyperlipidemia,
increasing age, surgery, prolonged immobility,

Studies
Doppler ultrasound of the lower extremity confirms with
good sensitivity and specificity if DVT is present. It has the best
predictive value for a DVT. However, it can be over- used, which
causes significant expense.

D-dimer is a small protein fragment present in the blood after

a blood clot is degraded by fibrinolysis.
o Relatively sensitive, but poorly specific test for the presence of DVT
o Negative result (low D-dimer concentration in the blood) practically
rules out thrombosis
o Positive result may indicate thrombosis, but does not rule out other
potential causes.
o D-dimer is useful in excluding thromboembolic disease when the
probability is low.

DVT therapy
Goals of therapy for DVT
1. Immediate inhibition of the growth of
thromboemboli
2. Promotion of thromboembolic resolution
3. Prevention of recurrence
Heparin achieves the first goal, it encourages
the 2nd by allowing fibrinolytic dissolution to be
achieved unopposed. It is available in two forms:
Unfractionated heparin orlow-molecular

LMWH v. unfractioned Heparin

LMWH has several advantages overunfractionated heparin:
Longer biologic half-life soit can be administered subcutaneously once
or twice daily
Laboratory monitoring is not required
Thrombocytopeniais less likely although periodic monitoring of
platelets may be needed
Dosing is fixed
Hence,LMWH may be used in the outpatient setting.
Unfractionated heparin requires hospitalization asit is
administeredintravenously with the dosage based on body weightand
titrated based on the activated partial thromboplastin time.

Prolonged Prophylaxis
Warfarin
Not suitable for initial therapy in thromboembolism because their onset
of action is too slow.
Role is in maintaining anticoagulant protection for prolonged periods.
Monitor warfarin dose by measuring the INR and titrate the warfarin
dose every three to seven days to an INR of 2.0-3.0.
Factor Xa inhibitors
Does not require weekly lab monitoring of INR and therefore makes
adherence an easier process.
Fondaparinux is the parental form of the drug and could be used instead
of LMWH.
Rivaroxaban is an oral factor Xa inhibitor and might be used in place of
warfarin.
Although these drugs have been found to be generally as safe and
effective as warfarin and LMWH, the negatives of this class of
medications includes high cost and difficulty in reversing the
anticoagulation in the face of a bleed.

More than 95% of pulmonary emboli arise from thrombi in

the deep venous system of the lower extremities.Ninety
percentof deaths due to pulmonary embolism result within
an hour or two -- before diagnostic and therapeutic plans
can be implemented. Therefore, prevention and prompt
treatmentof DVT is the most effective approach to
prevention of, and death due to embolism.
Trt as outpatient if:
Hemodynamically stable
Good kidney function
Low risk for bleeding
Stable and supportive home environment

Diabetic Foot Exam

Often in diabetics, foot ulceration is the result of impaired
sensation(distal symmetric polyneuropathy)and impaired
perfusion(diabetes vasculopathy and peripheral arterial disease).
Sensory testing, according to the American Diabetes Association (ADA),
can be conducted witha 10-gram monofilament plusany one of the
following: vibration using 128-Hz tuning fork, pinprick sensation, ankle
reflexes, or vibration perception threshold.
Assessing the arterial supply to the lower limbs and feet (pedal
pulses)is essential in evaluation for peripheral arterial disease. It is
thestrongest risk factor for delayed ulcer healing and amputation in
diabetes patients. Also, skin changes such as hair loss and temperature
changes may signal arterial insufficiency.
Inspecting the feetand footwear is important to prevent ulcers which
are usually caused by breaks in the skin due to accidental trauma or
poorly-fitted footwear. The patient's feet should be inspected for breaks in
the skin, pressure calluses that precede ulceration, existing ulceration and
infection, and bony abnormalitiesthat lead to abnormal pressure