SWOLLEN LEGS

OTHER COMMON CAUSES

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VENOUS OBSTRUCTION BY PELVIC MASS  LYMPHODEMA   INFECTIONS   MEDICATION

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PELVIC MASS

 PREGNANCY

 BENIGN OR MALIGNANT  OVARIAN AND UTERINE MASSES  BLADDER MALIGNANCY  

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PREGNANCY

 You are in a consultation with  19 years old female patient. She is 28 weeks pregnant, G2 P0+ 1TOP. PMH nil. She has come for ante-natal check up. C/O swollen ankles over last few weeks , shoes not fitting.Swelling improves in the morning.  Brought to you by

1. What else you want to know or do?2. What is your differential?

- BP 126/78,  booking BP 120/70- urine protein nil- no other complaints- good foetal movements Physiological Edema-Pre-ecclampsia-DVT

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What is the diagnosis?How will you explain to her?What will be your advice to her?

PHYSIOLOGICAL

Cause - fluid retention - pressure of gravid uterus

 Advice- avoid long sitting and standing.-drink more water.-avoid tight footwear.- if excessive swelling or no diurnal variation-- inform

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PELVIC MASSES

You are seeing a 65 years old female patient coming for a routine check up. PMH- Hypertension . Meds- Bendroflumethiazide 2.5mg OD, AdcalC/O Feels bloated, pants dont fit well.Noticed swelling feet over last couple of months.Eats well, denies weight loss.No change in bowel habits, no sob/CPNo post menopausal bleeding or discharge,v occ. brownish discharge. OE- HR 70/min reg, BP 136/80, JVP not raised, pedal edema B/L, chest clear, abd- vague suprapubic fullness ? massPV- no bleeding/ discharge, cervix normal, ?uterus ? mass in left adnexa

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What do you want to do and how you tell the patient?

 Urgent USS abdomen+ pelvis ? tumour markers 2 week ref. to gynaecologist.

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LYMPHOEDEMA

 MALIGNANT INVOLVEMET OF LNs  POST SURGERY/ RADIOTHERAPY  INFECTION- FILARIASIS  CONGENITAL- MILROY'S DISEASE

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LYMPHOEDEMA

This is a 48 years old male patient who has come to see you in surgery today. He had excision of a melanoma  on his left thigh followed by block lymph node dissection in his left groin, a month back. He is doing well. OE- His wound has healed well.  He read about leg swelling after this operation on internet and was also told about this before surgery but is not quite clear about it. He asks you what is lymphoedema and how to avoid getting it.What will be your advice to him?

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LYMPHOEDEMAWhat is lymphoedema?   Advice - keep skin clean and dry- avoid any cuts or tears- avoid extreme temperatures-no IV/injection/BP/ needle stick on the affected side-compression stocking while flying-avoid infection, any sign- contact GP

Six months later , you are seeing him again in the surgery.C/O swollen left leg ,  no pain but feels tight, warmOE- non pitting swelling ,no erythema, non tender  What is the diagnosis?What are the options?  

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LYMPHOEDEMA - management

In early stages-- Elevation Referral to Lymphoedema clinic - Manual lymph drainage- compression bandaging and stockings- specialist footwear  Recurrent cellulitis-- prophylactic antibioticsDiuretics- no help

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INFECTIONS - Cellulitis

You are on call and doing the triage.You see a 24 years old male who has swelling on left leg. He says that he woke up this morning with this swelling. He had just been back last evening from a 3 days holiday in Spain. He is otherwise well, just a bit tired. PMH- nil.                    OE- temp. 36.5deg, mid calf is swollen with surrounding erythema, tender What are the differentials?                                                                              

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CELLULITIS

-Treat with oral antibiotics  Penicillin V 250-500mg QDS/ Erythromycin -7-14 days-Elevation-Worsening advice  A day later, he attends again, looks quite rough, says has been feeling hot and cold.temp. 37.5deg, left leg and foot swollen and red with some blisters. Urgent referral to hospital - needs IV antibiotics

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MEDICATION

 CALCIUM CHANNEL BLOCKERS NSAIDS STEROIDS  HORMONES-- OESTROGENS[ CONTRACEPTIVE PILL, HRT], TESTOSTERONE  ANTIDEPRESSANTS - MAO#, TRICYCLICS

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MEDICATION

You are reviewing a 55 years old female patient for her medication review. PMH - Hypertension, AsthmaMedication- Amlodipine 5mg OD, Clenil modulite inhaler 2puffs twice a day, ventolin inhaler 2 puffs as required. She says that she has noticed that her ankles swell up.OE- BP 124/78, JVP not raised, chest clear, pedal odema both ankles LEG SWELLING DUE TO Ca channel # Change the antihypertensive to thiazide or ACE#explain to the patient.BP review arranged.

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