42 years old female patient with presentation of right leg swelling and heaviness. Presented to you in vascular clinic.
Q1: How would you approach this case?
This patient gave history of giving birth to three kids the youngest is 5 years old. She had previous treatment of DVT for 6 Months DOAC. Patient has high BMI. She was giving the diagnosis of lymphedema and was offered surgery for that.
- No signs of venous skin complication and patient have normal pulses and
- US duplex showed widely patent deep system with incompetent femoral vein. Normal superficial system.
- Questions?
- Q2. To what degree do you agree with previous diagnosis?
- Q3. Do you need any further investigations?
- Q4. What would be your treatment plan?
- Q5. How would you approach the patient in term of patient education regarding her condition and the set expectation for her prognosis?
A1- approach
1st history taking about patient complain ,type and extent of edema
if there is any skin changes or varicosities or ulcers
risk factors as prolonged standing ,obesity ,pregnancy
family history and surgical history
drug history for blood thinners
examination
examine ll for any varicosities ,sfj reflux any saphena varex or leg ulcers
arterial examination and peripheral pulsation
investigation
venous duplex to assess superficial and deep system
ctv may be indicated if there is any proximal cause
A2 mostly due to chronic venous insufficeny as patient had a history of DVT
but may also had a lymphedema
A3 we need duplex assessment
and may need ctv to assess iliac veins for any compression
A4 treatment conservative is the mainstay like elastic stockking
elevation of leg ,reduce weight
venotonics
may be surgical rule if there is any obstruction or compression may need venoplasty
A5 we must educate the patient about risk factors like obesity ,prolonged standing
the importance of elastic stocking and conservative treatment
there might be other complication and signs like ulceration and pigmentation if patient didnt stick to his treatment
and patient may need to know that it is a chronic condition and it may take long time to improve
1- venous duplex , complete family history of similar conditions , detailed history onset , course , duration, any provoking factors
2-not agree
3- another venous duplex +_ ct venography
4-duplex of iliac veins repeated rot lower limb if free proceed with cdt + physiotherapy
5- weight reduction, avoid any skin infection, good skin care with emulent — long term physiotherapy with cdt( complete decongestive therapy)
Q1 approach
History of contraception, long standing
Edema : onset, cource , what increase, what decrease, nature, alleviating&precipitating factors
Q2
May be true as hugm BMI beside venous system is free
But there is reflux at deep system with history of ch dvt so most propably venous edema
Q3
Compression us
Dynamic duplex venous ( up right- sleep positio )
Q4
Gradual compression elastic stockings
Life style modification
Regular exercise
Body wt down
Q5
By educating her
Exercise of calf ms strength
Body wt decrease
No contraceptive pills
Elasctic stocking
Leg elevation during sleep
Q1 approach
History of contraception, long standing
Edema : onset, cource , what increase, what decrease, nature, alleviating&precipitating factors
Q2
May be true as hugm BMI beside venous system is free
But there is reflux at deep system with history of ch dvt so most propably venous edema
Q3
Compression us
Dynamic duplex venous ( up right- sleep positio )
Q4
Gradual compression elastic stockings
Life style modification
Regular exercise
Body wt down
Q5
By educating her
Exercise of calf ms strength
Body wt decrease
No contraceptive pills
Elasctic stocking
Leg elevation during sleep
Q1 : compleat history taking to determine Risk factors .
Analysis of the pain to exclude arterial and neurological pain from that of venous origin.
Examine the limb , for pulse ,coldness,tenderness
Q2: I agree to some degree , lymphedema could be the cause of this patients complaint.
But the character of pain in this patient the history of DVT is more likely could shift the Diagnosis to post thrombotic syndrome. Chronic venous insufficiency.
Q3: follow up detailed Venous Duplex
Q4: compression therapy , Venotonics, limb elevation , venotonic drugs
Q5: health education, limb elevation and importance of adhring to conservative ttt for better prognosis
1:
Go for history taking of the her complaint, starting from onset, course ,duration aggravating/relieving factors. Ask for Oral contraceptive therapy before pregnancy and in between, history of DVT and how many times
Then, local vascular examination, Ultrasound Duplex examination.
2: to diagnose lymphedema the foot and leg must have special cccs of swelling and not related to DVT or venous insufficiency
3: CT venography is highly recomended to estimate the patency of iliac veins. And pelvic veins
4: Conservative management: starting from exercise ,weight loss , GCS And limb elevation.
5: Explain to the patient the nature of her disease and at which level , the importance of wt loss and compression therapy as it is very beneficial and will improve her symptoms so much ,and as long as she is following the instructions and taking the precautions symptoms will be relieved and quality of life will be much better
A1 history, taking, including previous history of DVT and parity presence congestion symptoms presence of Venus, claudication or leg heaviness characteristics of venous limb as decreasing of the pain with leg. Elevation / increasing pain at the end of the day or after prolonged standing and characteristics of the pain as heaviness
A 2 I disagree with the diagnosis of lymphedema as patient has the pain and edema, following the lower DVT, and as evidence said by the duplex and the presence of deep venous insufficiency
A3 it’s recommended for visualizing the iliac vessels and the IVC along with the pelvic veins to do CTV which may present iliac vein lesion eligible for venoplasty or the presence of pelvic congestion
A4 first of all it’s advised for having elastic stocking and avoiding prolonged standing with leg elevation while seated and sleeping also weight loss is very important if there is a residual stenotic lesion within the iliac vein and if the patient has active ulcer. It’s recommended to do venoplasty with stenting
A5 patient should be educated that has that her condition is chronic and needs lifestyle modifications in terms of weight loss and using elastic stocking that helps in the venous drainage of the lower limb and prevents the subsequent lipodermatosclerosis and ulcer.
And that we will we will follow up the case regularly to see the condition if it’s improving or deteriorating, which may require using further investigations as a CT venography and subsequent interventions if needed
Really good answers from all of you.
I would only recommend to be on the patient side when it comes to patient education. I mean do not scar them but at the same time give them way out of there concerns. You can say the same things in two different ways for example
1) if you don’t follow this advice you may get this or that.
2) if you really wants to feel better you should do this and that. otherwise things could get a lot worse.
A1: Detailed history taking of the main complaint, especially characteristics and onset of swelling, aggravating/relieving factors. I will ask about pregnancy details and whether the patient recieved any hormonal therapy.
I’ll then perform a local examination and ask for Ultrasound Duplex scan.
A2: Given the high bmi of the paitent and previous DVT, i suspect Chronic Venous Insufficiency.
A3: CT venography and MTV
A4: Conservative management:
-I would encourage weight loss and receiving regular exercise
-Anti-coagulant therapy
-Leg raising to reduce edema and elastic stockings.
A5: I will explain to the patient her current condition and the prognosis of CVI. And will establish a treatment plan with the patient and explain the importance of exercise and weight loss in relieving her symptoms.
1-Approach through detailed history about the swelling as main complaint regarding its onset and , duration,and course: if acute and short period then what are the ass symp like pain, site of pain, calf rigidity and other symp of acute dvt, birth control pills, recent bed bound, surgeries or fractures, family history of dvts, previous dvts
If prolonged history then hx of previous dvts, abd or limb surgeries, malignancies, surgeries for varicose veins, leg ulcers, family history of lymph edema, travel to tropical areas
Aggravating and relieving factors
Clinically : by inspection extension of swelling, skin condition, visible varicosities, scar of saph vein harvest, scar of inguinal incision or pelvic surgeries
Palpation of skin temp, pitting or not, calf ms laxity, thrill on cough, limb pulses, abd or pelvic masses
2-lymphedema is taken into consideration but CVI especially iliac outflow obstruction, valve incompetence should be excluded given the history of dvt ttt period 6 months so venous duplex exam is recommended
3_ I will ask about rt fem wave form during respiration and Valsalva maneuver and comparison with lt fem vein if not conclusive go for direct look on iliac vein but increased BMI makes it hard for sonographic look on iliac veins, so CTV or MRV is needed to assess iliac vein
4- talking about PTS WITHOUT complications I will manage it conservatively by compression therapy, body weight control, calf ms exercise
5-importance of conservative management and healthy life style to avoid case progression into venous claudication or skin changes, pain, heaviness, eczema and eventually venous ulcers
History :
complaint : onset , course, duration ,level of swelling , what increase ? like prolonged standing, what decrease ?limb elevation, pelvic symptoms for pelvic venous congestion
any general symptoms like cardiac, renal, hepatic , weight loss due to malignancy, last menstrual period for malignancy
medical history : DM, Hypertension, DVT, hyperlipidemia, Ischemic heart disease , CKD, CLD, pregnancy, autoimmune disorder, thrombophilia
medication: anticoagulation,OCPs
surgical history: any intervention to the abdomen ,Venous intervention like EVLA or sclerotherapy
Family history of VV, DVT, thrombophilia
social: Occupation, IV drug abuse
examination :
general :
check for generalized edema
blood pressure if hypertensive
local: inspection :
trophic change like ulcer , level of the edema , VV , SFJ (saphena varix)
palpation
pulse , edema pitting or non pitting, VV , scar
trendelburg test
investigation
labs : KFT, lipid profile ,LFT, thrombophilia profile
radiological: duplex
Treatment
life style modification : exercise, avoid prolonged standing , leg elevation, weight loss
medication : anticoagulation if DVT
elastic stocking
intervention: if primary VV consider EVLA, foam sclerotherapy, HLS
Q2: I disagree with the diagnosis , as refluxing femoral vein may be the cause for her symptoms , she has history of DVT
Q3: Thrombophilia profile
CT venography to exclude may thurner syndrome
Q4: Life style modification : exercise, avoid prolonged standing, good hydration , leg elevation, weight loss
elastic stocking
Q5: teach her that she has a chronic condition due to her previous DVT which cause impairment of the drainage of her limb which will cause perminant swelling
following the medical advice regarding elastic stocking and leg elevation may help improve the symptoms , if the pain or the swelling increase she may seek medical advice to rule out DVT.
comprehensive approach is necessary, as full medical history and examination
>> History:
I will ask about the initial trigger of the old DVT, the treatment duration, and any residual symptoms post-treatment.
* Pregnancy History: any previous VTE during pregnancies?, any events of abortions
* Medications: especially hormonal therapies. like ccps
* Symptoms: Characterize the swelling (acute vs. chronic), pain, skin changes, and functional limitations.
>> Examination:
Inspection of both legs for swelling, asymmetry, pitting/non-pitting edema, skin changes (hyperpigmentation, ulceration, lipodermatosclerosis).
Palpation for tenderness or warmth.
Check for signs of lymphedema (Stemmer’s sign).
and check arterial pulses.
Q2 given the history of DVT, and the obesity, with the duplex finding of femoral vein incompetence, i see the diagnosis is mre like CVI rather than lymphedema
also maybe there’s a mixed pathology in this case of CVI and lymphedema
Q3 yes I need to do CT venography yo assess if there is higher venous pathology like ilio caval Obstruction,
regarding lymphedema with the current information I will do nothing except if there’s persistent symptoms even with good management of CVI, then I will do lymphoscintigraphy to assess the lymphatics.
also If there’s history of abortion or recurrent DVT I will ask for coagulation profile labs to exclude thrombophilia.
Q4 in this case i will go with the Conservative management in the form of :
> Compression Therapy: Graduated compression stockings it will help in case of the CVI and lymphedema.
> Elevation: Elevating the legs above the heart can help reduce edema.
> Exercise: Regular physical activity can promote venous circulation and improve the heaviness sensation .
> Weight reduction : as obesity alone can produce odema through venous compression as you stated before in the lecture.
the case may need endovascular intervention if we find a higher significant obstruction.
Q5 Regarding counselling of the patient
> I will provide clear and Concise Explanation of the condition of CVI in simple terms, and highlight tge possibility of being mixed pathology case.
> also I will set realistic expectations for her as the limitations of treatment and the possibility of persistent symptoms.
> I will make sure to highlight the importance of lifestyle change: as the importance of compression therapy, exercise, and weight management.
> Follow up: regular follow up to monitor symptoms, adjust treatment, and address any concerns.
> will provide reassurance and address any anxiety or depression related to the condition.
A1: At first, I would take a full medical history including his medications and previous surgeries, prolonged incumbency, level of mobility and history of previous DVTs also thrombophilia, and OCPs in addition to family history then I would start to get more information about swelling, when did it start and whether she noticed it before or not and its relation to prolonged standing and leg dependency an there is any difference if she elevated her leg or not then I will examine her in regarding the level of swelling and its degree and also the associated chronic venous insufficiency skin changes in addition to arterial examination
A2: according to the US result refluxing femoral vein could be the culprit for her condition and might be due to the the previous DVT causing PTS
A3: I would recommend CTV or MRV to exclude proximal obstruction or compression and to help with my treatment plan
A4: compression therapy
A5: first I would explain my diagnosis and advise her about the importance of compression therapy and instruct her to avoid prolonged standing and leg dependency together with weight loss to avoid complication of venous insufficiency like skin discoloration and and ulceration
1- By history taking:
Diabetic, HTN, hyperlipidemia,
Renal, IHD or hepatic.
History of previous DVT
Family history of thromobophilia.
Analysis of pain: onset, course, duration , precipitating and relieving factors.
Age of youngest child
Gynecological: Hx of PCS
Anticoagulants taken , OCPs
Operations done
By examination :
While standing…. signs of visible V.V, scars for operations
While sitting….edema pitting or not and the level
Check distal pulses of lower limbs
Calves are lax or not
Signs of cellulitis ( redness and hotness)
Venous ulcers: shallow ulcers.
Lyphedema… buffalo hump.
Investigations:
CBB, liver functions, kidney function, PT, PTT
Thrombophilia profile
Measurement of ABPI
Treatment of
DVT :
Full dose Anticoagulant, limb elevation and good hydration
If extensive DVT : CDT
V.V: easting stocking
EVLA in case of reflux
2- I disagree …. maybe PTS vs lipedema
3- Compression therapy
Maybe CTV or MRV
4- weight loss
Compression therapy
Good hydration
5- Education about good hydration, importance about weight loss , elastic stocking and limb elevation.
Q2. To what degree do you agree with previous diagnosis?May be misdiagnosed, refluxing deep system may be sequel of DVT or may be associated with obesity with normal venous anatomy. also, lymphedema itself may no an accurate diagnosis, may be lipedema.
Q3. Do you need any further investigations?if the picture was only heaviness, and the sonographer is eminent, I will not recommend any further investigation.
In this first visit, I won’t ask for CTV or lymphoscintigraphy before compression therapy effect on the case.
Q4. What would be your treatment plan?I will start compression therapy with close follow up and encouraging weight loss.
Q5. How would you approach the patient in term of patient education regarding her condition and the set expectation for her prognosis?For the patient, I will educate about the importance of compression as the cornerstone of the treatment plan and that the obesity itself may be the cause for these symptoms.
Prognosis will be stable if recommended therapy followed. if not, case may be worsened by swelling, more heaviness, night cramps, or even ulcers in the lower leg.
Q2. To what degree do you agree with previous diagnosis?
Duplex show Deep system incompetence
Obesity
No signs of cvi
High bmi
I Will consider the diagnosis as venous lymphedema vs lipedema
Q3. Do you need any further investigations?
Superficial US assessment will prove presence of venous lymphedema by increase skins thikness+couple stones aberrance in presence of excessive ll edemas or rich fat deposition in case of lipedema
Q4. What would be your treatment plan?
If lymphedema:Conservative ttt by elastic stockings
+anti edematous if there is edema to give symptomatic ttt
If lipedema weight reduction Vs liposuction by plastic surgery
Q5. How would you approach the patient in term of patient education regarding her condition and the set expectation for her prognosis?
IN case of lymphedema
Education about skin and foot care
Importantance of elastic stockings to relive symptoms and to prevent progression of diseases
IN caes of lipedema education about importance of weight reduction to prevent cardiovascular and orthopaedic complications
1 approach through
History : social , Medical , surgical , symptoms
Examination : inspection for visible vv , color change , ulcers. Palpation of the pulsation , warmth or if there’s tense calf or not
Investigations
Venous duplex and soft tissue us
2 it depends on examination if there’s signs of lymphoedema so it may be mixed chronic venous insufficiency and lymphoedema
3 I think duplex is enough
4 compression therapy
Medical ttt
Follow up
5 tell the pt the diagnosis CVI +/- lymphoedema which needs ttt for life it’s c3 according to classification. Ttt is for prevention to progress to more advanced stages in form of skin changes and ulceration and for improvement of the swelling . Follow up is needed as intervention may be needed in late stages with failure of conservative ttt
Q1:History taking is she diabetic or has Hypertension or any cardiac insult or any kidney problem is she smoker or alcoholic is she pregnant or not, if she has children will ask about the course of the pregnancy if she has any problem through and postpartum
then i will inspect both lower limb to asses if their is obvious difference between both lower limbs , inspect any signs of redness or collection in the leg, inspect any obvious dilated veins while standing
will examine her pulse bilaterally and if absent i will do ABI to assess severity of ischemia in the affected limb
then i will go for duplex ultrasound to examine arterial or venous system according to the results of the previous examination
Q2: totally disagree with lymphedema as the patient has previous history of DVT and duplex revealed incompetent femoral vein as post phlebitic insult which is going with venous hypertension post DVT
Q3:duplex ultrasound didn’t mention the site of previous DVT if it in the femoral vein or above that level so i may order CT venography to assess if there is any occlusion or stenosis above that level
Q4: if there is no lesion in the venous system above the level of the femoral vein i will go for compression therapy in the form of elastic stoking (30 mmhg) above the knee and will advice the patient to start program for weight reduction
Q5: i will inform her that this is due to her previous DVT and with strict compression therapy from the morning till the bed time that will help in reduction of the heaviness and swelling and if she will not do compression ulcer could develop and prognosis will be good with strict compression
A2:
Regarding the history PTS is more likely
A3:
Pelvic and abd US is not preferred due to high BMI. CTV for proximal iliac venous tree and excluding May Thurner synd
A4:
Weight reduction exercise
Compression therapy would be the best option for this scenario in the form of elastic stockings
A5:
Warning the patient of the complications such as lipodermatosclerosis 2ry VV DVT recurrence and venous ulcers and how to avoid
Follow up
The risk of recurrence of the DVT with future pregnancy and to consult her obstetrician regarding the contraceptive therapy
Question 1
HISTORY TAKING:
– The routine personal and past medical history (Cardiac, hepatic, renal history and nutritional status, however these usually cause bilateral equal lower limb edema)
– History of the present illness (Analysis of the swelling) :
Onset, course, duration
Does the swelling increase by standing and decrease by elevation, more at the end of the day less in the morning, does it improve by compression, does she receive any medication for her condition, is she improving or not
Acute onset favors acute DVT
– Ask about History of DVT to 1-differentiate primary from secondary (postphlebitic) varicose veins and to 2- determine the possibility of recurrence of DVT
If yes, is she on any anticoagulants and what dose
For provoked vs unprovoked DVT ask:
– Is she pregnant as pregnancy can aggravate varicose veins and can also cause compression of the pelvic veins provoking venous stasis and evenually DVT, hx of DVT during previous pregnancy and hx of abortions
– If not pregnant, is she on oral contraceptive because it can increase the risk of venous thrombosis
– History of long duration airborne travel
– History of recent prolonged recumbancy
– family history of varicose veins and lymphedema
– We can also ask about history of hernias, piles, flat foot for hereditary weak mesenchyme in case of varicose veins
– Recent traveling to endemic area with wuchereria bancrofti
– Occupational hx:
If she is a teacher or a surgeon (standing long hours in case of varicose veins)
– ask about history of trauma or knee osteoarthritis
EXAMINATION:
– Analysis of the swelling:
Pitting or not
To what level
Measure with tape and compare to the other side
– Signs of inflammation in the form of redness, hotness, tenderness to exclude cellulitis as a differential diagnosis for DVT as a cause for unilateral limb edema
– Inspection for dilated or visible veins and their courses
– Inspect for leg ulcers usually shallow, irregular, not infected, itchy especially at gaitre area with surrounding hyperpigmentation in case of varicose veins. Trial of topical medications and compression and response to ttt
– Inspect for any scars of previous surgery eg stripping or EVLA
– Inspect for the presence or absence of the ankle crease (intact in case of lymphedema)
– Palpate for tense tender calf muscles
– Palpate the inguinal lymph nodes
– Check for pulsations as a routine vascular examination, although arterial pathology is not associated with limb swelling, arterial ischemia most commonly present with limb wasting. In some cases, severe limb edema can cause impairment of arterial circulation on top, leading to phlegmasia alba dolens and phlegmasia cerulae dolens
– Trendelenberg test for venous reflux
Investigations
A)Imaging
– Venous duplex us is the gold standard commenting on deep venous system, superficial system, SFJ, SPJ, incompetent perforators, diameter of GSV & SSV, level of DVT (extensive or not) if present and comment if it is recent or old, site of superficial thrombophlebitis if present commenting on the length of thrombosed segment and proximity to deep system
– CTPA is the gold standard in case of suspected PE ( decreased spo2 and new onset dyspnea)
– Lymphscintigraphy in case of suspected lymphedema and intact superficial and deep venous systems
B)Blood tests:
– CBC (HB, TLC in suspected cellulitis, PLT count as a baseline reference before starting anticoagulants in case of DVT if the patient developed HIT later on)
– Kidney functions ( in case of DVT, heparin only will be given to patients with renal impairment- also if PE is suspected, kidney functions are needed before CTPA)
– PT, PTT, INR
– D-dimer and FDPs are not commonly done
– Thrombophilia profile in case of recurrent or unprovoked DVT
TREATMENT:
According to the cause
DVT:
– Full dose anticoagulants in case of acute DVT, along with leg elevation, elastic stockings
– In case of extensive DVT, this patient (young age) can be offered mechanical or pharmacomechanical thrombolytic therapy – with or without (debatable) contralateral IVC filter insertion pre operative for fear of PE during intervention- to prevent destruction of the valves and fibrosis with subsequent postphlebitic limb
– IVC filter insertion pre case of PE, failed, contraindicated or complication of anticoagulation
Varicose veins:
– EVLA is the gold standard first line in case of refluxing SFJ or SPJ. Injection sclerotherapy and direct attacks of smaller veins can also be done in the same session. Other options include RF ablation, Microwave ablation, stripping
– Graded elastic stocking or crepe bandages always give very good outcomes regarding venous ulcer healing and should always be offered to patients presenting with venous ulcer pre and post EVLA
Lymphedema:
– compression stocking should be offered
A1:
History taking;
Main complaint analysis regarding the pain and heaviness onset course and duration as well as the other symptoms that accompany including fever, swelling, discoloration, claudications and the nature of pain what it looks like. Factors that increase the pain standing walking climbing or getting down stairs as long as relieving factors rest leg elevation and its relation to standing and rest or exercise.
PMH of diseases DM HTN IHD renal or liver disease along with previos history of DVT.
Family history of venous disorders VV DVT with probability of thrombophilic disorders, arterial disease.
PSH of VV DVT or spine and arterial surgery and obs n gynecological surgeries
Gynecological symptoms as heaviness and pain in the pelvis or perineum vaginal bleeding may be due to pelvic congestion disease
Examination;
General examination BP HR
local examination; inspection of swelling color pigmentation and ulcers along with dilated veins over the legs and perineum and ischemic changes. Palpation of the oedema pitting and non pitting and the level of oedema with peripheral pulse detection and ABPI measurement. Neurological examination in the form of motor sensory and straight raising test.
Investigations;
Laboratory CBC BL.GLU KFT LFT thrombolphelia profile prot C S anti thrombin III factor V leiden anti phospholipid Ab lupus anticoagulant MTHFR gene mutation
imaging xray spine Doppler arterial and venous abd and pelvic US in case of pelvic venous disorder related symptoms trans vaginal US if PCS was suspected. CTV MRV in suspected ilio caval venous lesions, venography. CTA MRA with arterial disease and NCV along with MRI spine in cases of spine lesions.
Treatment;
Conservative with medications and life style modifications regarding the pathology
Compression therapy in the form of elastic stockings after exclusion of arterial cause multiple layers bandaging
Intervention including foam sclerotherapy VV ligation and stripping surgery EVTA. Ilio caval venoplasty with stenting as in case of May Thurner’s synd. In case of pelvic congestion with pelvic varicosity, embolization coiling and foam sclerotherapy of the ovarian vein and uterine VV are to be cosidered
TTT of the ulcer according to the pathology
Detailed history
Assessment of PT complaint onset coures
Risk factors for DVT
Life style
Examination of pulses and
Vv distribution if present
any signs of systemic diseases
any cyanosis or palor
Localized swelling or masses
Dd
Haematoma
DVT
Ruptured Becker cyst
Cellulitis
Ruptured gastrocnemius
Investigation
Routine lab
duplex us to prove or exclude DVT assessment of vv if present
Soft tissue us to exclude other causes
Provisional diagnosis DVT till proved not
Ttt according to examination+ lab+radiological result’s
At first I will ask questions for complaint analysis as onset ,course,duration and releasing and precipitating factors
As
1. sudden acute progressive swelling may diagnose DVT
2. Swelling and heaviness that is relapsing that appear by the end of the day or after prolonged standing or prolonged setting in work time and disappears after limb elevation may diagnose varicose vein
3. Swelling and heaviness that is of chronic gradual and very slowly Progressive course mag diagnose lymphedema .
History of previous DVT is important it will raise the suspicion of new DVT OR PTS.
History of OCP for contraception is important
I will then proceed for examination for the other limb as there may be edema in the other limb and that will raise the suspicion in systemic causes of edema
Also I will exam edema it self if it is non pitting edema it will go with lymphedema
I should not forget Arterial system examination by checking peripheral pulsation
I will measure BMI for the patient to exclude obesity as a cause of
The complaint .
Finally I will ask for venous doppler
US. it will diagnose DVT or venous insufficiency either deep or superficial
If it comes normal then I will ask for lymphocyntegraphy
Q2. I disagree with the given diagnosis without exclusion of PTS at first as the patient gives history of DVT and of course it could be the beginning of it by leg swelling and sensation of discomfort especially in the venous duplex there is deep venous insufficiency
Q3.. I will ask for CT Venography for pelvic and ll veins as or MRV to exclude may turner syndrome as a possible cause of venous incompitance
I will ask for lymphosyntegraphy in CTV OR MRV are negative
Q4.. my treatment plane will be in
a patient with just edema and heaviness which is CEAP class C3
1.Patient excercise and weight loss
2. and elastic compression stalking exerting pressure about 20-40 MMHG around ankle joint according to the guidelines to reduce edema and severity
The above if the pt will not undergo intervention or refusing intervention
If there is venous out flow obstruction in angiography so intervention should be considered if conservative treatment fail to control symptoms and we should consider endovenous intervention first then if it fails we should consider surgical intervention
Q5. I will explain CVI clearly to the patient what is it , symptoms ,signs and expected deterioration of symptoms in the form of skin changes up to venous ulcers but only this to raise the attention of the patient about the chronicity of the condition but also I will also reassure the patient that those symptoms are easily to be controlled by proper conservative treatment and proper intervention
Q1: How would you approach the case?
Initial Assessment:
Detailed History:
Onset and progression: Sudden or gradual onset, worsening over time, associated symptoms like pain, warmth, redness. Previous DVT: Duration of anticoagulation, risk factors, recurrence. Pregnancy history: Complications, thromboembolic events. Medical history: Hypertension, diabetes, hyperlipidemia, smoking, family history. Medications: Current medications, including anticoagulants. Lifestyle factors: Sedentary lifestyle, occupational hazards, travel history.
Physical Examination:
Lower limb: Swelling, tenderness, warmth, erythema, venous ulcers, skin changes. Pulses: Femoral, popliteal, dorsalis pedis, posterior tibial.
Cardiovascular: Heart rate, blood pressure, heart sounds, murmurs. Abdominal examination: Liver, spleen, kidney enlargement, abdominal tenderness.
Investigations:
Ultrasound Duplex: Assess deep venous system for thrombosis, reflux, and superficial system for varicose veins. Blood tests: Complete blood count, renal function tests, liver function tests, coagulation profile, lipid profile
To what degree do you agree with the previous diagnosis?
Given the history of DVT, high BMI, and normal superficial system, lymphedema is less likely. The persistent swelling and incompetent femoral vein suggest chronic venous insufficiency (CVI) as a more probable diagnosis.
Do you need any further investigations?
. Venography: To visualize the venous system in detail, especially if ultrasound is inconclusive. C.t venography and MRV
What would be your treatment plan?
Conservative Management:
Compression therapy: Graduated compression stockings to improve venous return and reduce swelling.
Elevation: Elevate the affected leg above the heart level to reduce edema.
Exercise: Regular exercise, especially walking, to improve circulation.
Weight management: Weight loss to reduce venous pressure.
How would you approach the patient in terms of patient education regarding her condition and the set expectations for her prognosis?
Explain the condition: Clearly explain CVI, its causes, and symptoms. Treatment options:
Discuss the benefits and limitations of conservative and interventional treatments.
Lifestyle modifications: Emphasize the importance of compression therapy, elevation, exercise, and weight management.
Prognosis: Explain that CVI is a chronic condition, but with proper management, symptoms can be controlled, and complications can be prevented.
Follow-up: Regular follow-up visits to monitor the condition, adjust treatment as needed, and address any concerns.