Mr. X is a 60-year-old Hispanic man with medically non-compliant DM and HTN who presents with bilateral lower extremity edema and left lower extremity pain. Mr X was in his usual state of health, until one week ago when he developed pain on his left lower extremity, described as dull, non-radiating and associated with erythema over the dorsum of his foot. He reports subsequent bilateral lower extremity edema. He admits to dyspnea on exertion. He denies fever/chills, pleurtic or any type of chest pain, hemoptysis, palpitations, PND and orthopnea.

Surgical hx: none
Med hx: DM, HTN
Social hx: 40-pack-year hx, hx of etoh abuse

This one may be a breeze for residents but for students their's a twist to this case.

You can only ask one question either on the history or on physical exam.

Mr. X is a 60-year-old Hispanic man with medically non-compliant DM and HTN who presents with bilateral lower extremity edema and left lower extremity pain. Mr X was in his usual state of health, until one week ago when he developed pain on his left lower extremity, described as dull, non-radiating and associated with erythema over the dorsum of his foot. He reports subsequent bilateral lower extremity edema. He admits to dyspnea on exertion. He denies fever/chills, pleurtic or any type of chest pain, hemoptysis, palpitations, PND and orthopnea.

Surgical hx: none
Med hx: DM, HTN
Social hx: 40-pack-year hx, hx of etoh abuse

This one may be a breeze for residents but for students their's a twist to this case.

You can only ask one question either on the history or on physical exam.
Lung sounds?

Lung sounds?


Bad leviathan......shaking head :laugh:


Of course.........vitals!!

How about more of a description of the erythema over the dorsum of his foot? In a real clinical situation, just looking at the patient's left lower extremity could rule several diagnoses in or out.

is the foot hot or cold?

Yep-
1.ABCs including lung sounds
2. V/S
then
my PE query
3. LE pulses and their character?
my Hx. question
4.ANY trauma?

Lung sounds?

CTA bilaterally

Bad leviathan......shaking head :laugh:


Of course.........vitals!!

BP 130/70 HR 103 RR 20 [the respiratory rate at our hospital is always 20!]
Temp = 98.7 Pain 4/10

How about more of a description of the erythema over the dorsum of his foot? In a real clinical situation, just looking at the patient's left lower extremity could rule several diagnoses in or out.

In terms of more of a description just by looking at it, can't say much other than that he had mild erythema confined to the dorsum of the foot.

Yep-
1.ABCs including lung sounds
2. V/S
then
my PE query
3. LE pulses and their character?
my Hx. question
4.ANY trauma?

Airway patent, lungs clear, carotid pulses intact. Bilateral lower extremity pulses were not palpable with the exception of a faint left femoral. Patient denies hx of trauma.

Unanswered questions from above then I'll ask my own:
History: trauma?

Physical exam: LE pulses/character and hot vs cold

Ah, you were working on that I see... ok for me then

Physical exam: abdominal exam paying attention to pain or tenderness, enlarged liver or spleen. edema to genitals and/or abdominal wall/flanks. any discoloration of abdominal skin? Is that one physical exam question?

Ah, you were working on that I see... ok for me then

Physical exam: abdominal exam paying attention to pain or tenderness, enlarged liver or spleen. edema to genitals and/or abdominal wall/flanks. any discoloration of abdominal skin? Is that one physical exam question?

Abdomen was soft, nt/nd. no hepatosplenomegaly. 2+ edema confined up to just below the knees. no abdominal discoloration. the foot was cool to touch.

just curious, what would abdominal discoloration point u to?

When you say the LE was cold, I take it one side was noticeably colder than the other.

How about a cardiac exam?

When you say the LE was cold, I take it one side was noticeably colder than the other.

How about a cardiac exam?

The left lower extremity was cooler than the right. Cardiac exam did not reveal elevated jugular venous pressure, RRR, no murmurs, S1, S2, no extra heart sounds. apical impulse hard to access

The infection (cellulitis) led to inflammation, which led to coagulation, which caused the condition, phlegmasia alba (or cerulea) dolens.

So, in order for me to pin down the diagnosis to one or the other of the above, I ask my one question: What color is the leg?

The infection (cellulitis) led to inflammation, which led to coagulation, which caused the condition, phlegmasia alba (or cerulea) dolens.

So, in order for me to pin down the diagnosis to one or the other of the above, I ask my one question: What color is the leg?

That seems to fit pretty well, though it doesn't explain why the patient has bilateral LE edema. Phlegmasia cerulea/alba dolens is usually unilateral.

i'm not sold on pcd yet, but it should be on the differential. foot isn't blue....does it blanch?

chronic venous insufficiency sounds pretty good to me based on color of the foot and not so impressive pain. does it get better when he elevates the leg?

I'd like to know about the patient's beans. Is he urinating as much as usual? Any other edema (periorbital, scrotal)? I still like PC/AD, but I'm also thinking post-infectious glomerulonephritis, under the assumption that the erythema on the foot is a group A Strep cellulitis.

The infection (cellulitis) led to inflammation, which led to coagulation, which caused the condition, phlegmasia alba (or cerulea) dolens.

So, in order for me to pin down the diagnosis to one or the other of the above, I ask my one question: What color is the leg?

I will enter a faculty hint if you guys desire it. If not, I'll stay out.

The infection (cellulitis) led to inflammation, which led to coagulation, which caused the condition, phlegmasia alba (or cerulea) dolens.

So, in order for me to pin down the diagnosis to one or the other of the above, I ask my one question: What color is the leg?

His lower extremity is not cynotic.

i'm not sold on pcd yet, but it should be on the differential. foot isn't blue....does it blanch?

chronic venous insufficiency sounds pretty good to me based on color of the foot and not so impressive pain. does it get better when he elevates the leg?

pain gets worse on elevation of leg and relieved when left dangling over the bed.

There are enough pieces to the puzzle to lead you to further question a particular diagnosis. It hasn't been mentioned.

I'd like to know about the patient's beans. Is he urinating as much as usual? Any other edema (periorbital, scrotal)? I still like PC/AD, but I'm also thinking post-infectious glomerulonephritis, under the assumption that the erythema on the foot is a group A Strep cellulitis.

edema only on LEs. urinating as usual.

I know I already shot my questions, but it's been about 6 hours.
Ever had a colonoscopy?



To jump on the diff. train...
I would be considering some form of caval syndrome given the bilateral edema.

[QUOTE=fuegorama]I know I already shot my questions, but it's been about 6 hours.
Ever had a colonoscopy?


No colonoscopy. Patient denies melena, hemachezia, changes in bowel habit, weight-loss.

go back and put the puzzle together. someone asked crucial question/s.

pain gets worse on elevation of leg and relieved when left dangling over the bed.

One side or both? Did the patient first notice this recently or has this been going on for a long time?

I would appreciate a temporal description as the hand requested.

Recognizing that I am well onto the savannah-
Is there a gluteal pulsatile mass?

the dangling leg history points to pvd. that and history of smoking plus diabetes. pulselessness and pain, but no pallor? i'm going to assume he's numb from as a side effect of the diabetes, and call the bilateral edema a red herring related to his chf. the slow onset and dull pain fit reasonably well. is there claudication? rest pain?

Can I get a CBC and a sed rate (and LFTs just for fun)?

the dangling leg history points to pvd. that and history of smoking plus diabetes. pulselessness and pain, but no pallor? i'm going to assume he's numb from as a side effect of the diabetes, and call the bilateral edema a red herring related to his chf. the slow onset and dull pain fit reasonably well. is there claudication? rest pain?

good job. i think u also asked a key question earlier---about whether the extremity being cold or warm.

so i'll recap and give the diagnosis:

Patient is a 55-yo HM with some key history including untreated DM, HTN, and a 40packyear hx. The guy comes in with complain of left lower extremity pain and bilateral lower extremity edema. He had no clinical symptoms to point to CHF (e.g. no orthopnea, PND, cough, no hx of progressive physical intolerance).

On exam, his foot was erythemic, and as somone asked: the erythemic FOOT WAS COLD compared to the opposite foot. another key, which someone else asked about but no one seemed to bother with after i mentioned it, was his pulses! i mentioned they were not palpable with the exception of faint right femoral!

we ran off and got a handheld vascular doppler and were able to hear faint pulses in the lower extremities with the EXCEPTION of the dorsalis pedis on the right. on lifting the patient's left leg to 90degrees the dorsal foot erythema magically disappeared! a positive buerger sign! we consulted vascular surgery. the dude had underlying chronic peripheral arterial insufficiency with an acute occlusion to the left lower extremity. they took over the dudes case so dont know what happened. but they planned an urgent angiogram with possible by-pass surgery.

guys like these, get relieve with dangling their legs or being in the sitted position which can lead to dependant edema. i'm guessing his kidneys are also dumping protein secondary to his very poorly controlled DM which can also explain the edema. on exam his lungs and heart were normal.

afterward, i read some articles on the topic, turns out this type of case if not caught of mismanaged,can get u in court. some docs are quick to dispense antibiotics to these guys thinking the erythema is cellulitis, without assessing if the limb is cold or warm or checking pulses!

Good job. I was thinking Charcot foot initially.

Here's a related article (http://bmj.bmjjournals.com/cgi/content/full/318/7188/925) in case anyone's interested.

Good case, in that it serves as a reminder to consider ischemia in patients with pain in the foot or leg. The absence of distal LE pulses as well as the finding of dependent rubor + pallor on elevation gave it away. However, I think that the finding of bilateral LE edema clouded the diagnosis a little at first, as did the combination of acute & chronic arterial occlusive disease. Patients with chronic disease usually report a long history of claudication, while patients with acute disease usually won't wait a week before coming to medical attention as this patient did.

Good case, in that it serves as a reminder to consider ischemia in patients with pain in the foot or leg. The absence of distal LE pulses as well as the finding of dependent rubor + pallor on elevation gave it away. However, I think that the finding of bilateral LE edema clouded the diagnosis a little at first, as did the combination of acute & chronic arterial occlusive disease. Patients with chronic disease usually report a long history of claudication, while patients with acute disease usually won't wait a week before coming to medical attention as this patient did.


the beauty and challenge of medicine. i'm a fourth year med student and remember doing more than a couple thousand vignette questions preparing for step one and for shelf exams, but not qbank or any other question bank helped with this case. 'real life' presentations don't read textbooks.

Good case and a great distraction for my Step 2 prep. There was one little error in your otherwise great description that kinda threw me.

another key, which someone else asked about but no one seemed to bother with after i mentioned it, was his pulses! i mentioned they were not palpable with the exception of faint right femoral!

Actually you wrote
Bilateral lower extremity pulses were not palpable with the exception of a faint left femoral.

This led me down the road of intermittent fem. art. compression by pelvic mass vs. persistent bilateral sciatic aa.

Thank you for taking the time w/this. The online vignette discussion is just another addicting facet of SDN.

BKN-
What hint were you going to give?

BKN-
What hint were you going to give?

Oh, I was just going to suggest that at that point you knew:

1. The legs were swollen
2. One leg was cold
3. And there were no pulses except a weak one in the left femoral

And I was going to say, does it sound like the problem is
A) arterial
B) local
C)venous?

I think we're doing a poor job of teaching vascular disease to medical students. Younger docs tend to concentrate on the swelling and erythema (if any) and come to DVT or cellulitis. They are pretty common. However, given the facts above, the patient has to have peripheral arterial occlusion. He could have the others also, but you should use Occam's razor.

The real issues for diagnosis are whether the occlusion is acute or chronic, thromobotic or embolic, and at what level. Finally, is immediate surgery or embolectomy indicated? If the pain was of sudden onset, you've got about 2-3 hours to save the leg. More often, this is a subacute to chronic process.

The symptom of pain relieved on dependency is useful, if present. I doubt that it's sensitive enough to be reliable.

The 2 questions I would have asked would be: "Are you impotent?", "Do you have pain in your buttocks on walking?". If he answered yes to both in combination with an absent femoral pulse, you've defined LeRiche's syndrome. LeRiche described it as diagnostic of occlusion of the aotro-iliac bifurcation. I've think it reliable.

There's also a cheap and easy way to get a functional evaluation of the LE arterial tree.
1. If the pulses at the feet are bounding, there is no significant large vessel occlusion.
2. If the pulses are not easily found, get a blood pressure cuff and a doppler. Put the cuff on the mid-calf and find the PT or DP with the doppler. Pump the cuff up to occlude the vessel, then drop it down until hear the sounds again. That's the systolic pressure. Put that pressure over the brachial systolic to get the ankle/brachial index. Normal is .9-1.2. If this is what you get, the swelling (usually from chronic venous insufficiency) was hiding the normal pulses.

I hope you all have been taught this already.

Now the good part,
1. It the ABI was normal, but you have strong reason to believe that the patient has peripheral arterial disease, have him walk around the ED for 5 minutes. Immediately repeat the ankle pressures, often the pressure will have fallen precipitously, indicating a functional deficit. Refer the patient.

2. If the ABI was abnormal, Repeat the process with the cuff on the lower thigh and upper thigh. Draw out a diagram showing the pressures at each level. A drop of 30 torr across a single segment tells you that there is a significant occlusion:
Brachial to high thigh: aorto-iliac or iliac bifurcation
high thigh to low thigh: femoral bifurcation
low thigh to ankle: trifurcation

Always do both LEs. If there is disease on one side there is almost always disease on the other.

All this in 10 minutes without an image. This is how we did it before doppler ultrasound. When I was a surgical tern on a big vascular service, we did this to everybody referred to us. It was surprisingly accurate when compared to the arteriograms. Actually, when there was a discrepancy, it was because the arteriogram was showing us a clinically unimportant lesion.

The other part to remember is that diabetics also have small vessel disease. This often leads to failure when attempting to revascularize the larger vessels. The vascular labs even have this cute little 1 cm wide toe cuff to be placed around the great toe with a tiny strain gauge to measure the arterial wave. they can then generate a toe/ankle index to measure small vessel occlusion.

Anyway, enough said. As always, ask a simple question, you get a pageant.

ABIs have been thrown around as a "must get" during my IM and Surg. cores, but I have yet to see one done much less perform one myself. The leap to angio-imaging is a given at my main hospital.
I assume this is a time-saving habit for attendings. The only residency is FP. It could also be indicative of the huge and hungry Rads group we have up this way.




Anyway, enough said. As always, ask a simple question, you get a pageant.
Great pageant. Hopefully I can approach that kind of spray on my rotations.
Thanks.

Bad leviathan......shaking head :laugh:


Of course.........vitals!!
I wasn't treating this like a simulation where of course ABCs come first. Given the option of only asking one question, I was curious about the dyspnea on exertion and was thinking PE secondary to a dislodged DVT. The bilateral LE edema didn't quite fit that picture to me, though.

Anyway, enough said. As always, ask a simple question, you get a pageant.
This case was beyond my scope of knowledge, but it and your pageant were very interesting! :cool:

Thanks for the teaching points, BKN!

I wasn't treating this like a simulation where of course ABCs come first. Given the option of only asking one question, I was curious about the dyspnea on exertion and was thinking PE secondary to a dislodged DVT. The bilateral LE edema didn't quite fit that picture to me, though.


just giving you a hard time :D

just giving you a hard time :D
:p

ABIs have been thrown around as a "must get" during my IM and Surg. cores, but I have yet to see one done much less perform one myself. The leap to angio-imaging is a given at my main hospital.
I assume this is a time-saving habit for attendings. The only residency is FP. It could also be indicative of the huge and hungry Rads group we have up this way.


When it comes time to consider surgery, the imaging is essential. But I'm suggesting that if the primary and ED guys got good at the noninvasive stuff. a lot of patients would need neither referrals nor studies.

BTW everybody know Occam's razor? If not speak up,the lecture will much shorter than the last one and considerably more important.

When it comes time to consider surgery, the imaging is essential. But I'm suggesting that if the primary and ED guys got good at the noninvasive stuff. a lot of patients would need neither referrals nor studies.

BTW everybody know Occam's razor? If not speak up,the lecture will much shorter than the last one and considerably more important.

I'm all ears.

I'm all ears.

The simplest explanation is the best one.



[that's just for irony's sake.... BKN, please proceed]

The simplest explanation is the best one.



[that's just for irony's sake.... BKN, please proceed]

Not bad, but you know I can't leave it there. :)

William of Occam was a medieval logician who said (in Latin, not goin' there), "never multiply entities unnecessarily". I guess it's called his razor because it helps you to clean up confusion in a single slice.

In medical diagnostic terms, if you have a confusing set of symptoms and signs that can be explained by one disease or more than one disease, pick the single disease. It's more likely.

BKN's corollary is that if it's two common diseases and one rare one, pick the two common ones. ;)

any thoughts on schrodinger's cat? ;)

any thoughts on schrodinger's cat? ;)
I think he left the building with Elvis.

I think he left the building with Elvis.

Yeah, but can you prove it?

Take care,
Jeff

I think he left the building with Elvis.

Or is that only if you observe him leaving? Does he otherwise exist both inside and outside of the building?