Station 5

A young lady with unilateral leg swelling... in station 5. How would you approach this case.

First thing.. in the 5 minutes that you are given to prepare the case.. you should start thinking about the probable differential diagnoses:

1. DVT
2. Lymphoedema
3. Cellulitis
4. Less likely causes - may not be relevant but just standby at the back of your mind.. heart disease, kidney disease, liver disease etc..

Once you start seeing the patient.. you would likely be able to exclude or include the diagnosis and focus in that area more.

I had a patient recently in the ward with the exact problem.. So I told my other colleagues who are going for the exams to see this patient.. in this case.. she had DVT.

Getting the diagnosis of DVT is easy. So what it takes to have 2 in all the 7 components that is full marks? Of course while talking and examining her, keep her comfortable. DVT legs are painful. Any "ouch" will cause you big time "OUCHHHHH".

Once you have ascertained the diagnosis.. again aetiology and risk factors.. especially this young lady, 3 months post-partum.. DO NOT FORGET OCP history (she just delivered, so she might take the Pill). Next thing will come to your mind.. antiphospholipid syndrome (APLS). You now need to determine whether it is primary or secondary.. If secondary, in this part of the world, excluding systemic lupus erythematosus (SLE) is important.. so run through questions related to this and quickly look for the hard signs in the patient.. ie. rash, discoid lesions, alopecia, joint swelling, oral ulcers, vasculitc lesions etc..

Talking about APLS.. getting comprehensive Ob & Gyn history is very important.. number of pregnancies, at what month baby delivered, any complication during delivery ie. pre-eclampsia, any miscarriages (if yes, at what month?), status of the baby at birth and the current status.

Next is to look for complications and associated features ie. migraine, central venous thrombosis, pulmonary embolism, non-healing leg ulcer etc.

Above all else.. maintain patient's welfare and ADDRESS her concern. As she is still young, I am sure she is concerned about subsequent pregnancy, treatment and her future.. ie. can she work etc.

May sound long.. but try practising with your friends.. If you can't get all the points out during exam, getting some of the important once and MAINTANING PATIENT'S WELFARE might suffice.

If you are interested to know more about APLS.. I find this helpful...

1. Guidelines on the Investigation and Management of Antiphospholipid Syndrome
2. Patient information leaflet for Antiphospholipid syndrome

DVT is a very common topic in daily practise... from time to time I am sure we get referrals from our Ob & Gyn colleagues. So it is good to know about this...

In my patient.. the patient fulfilled clinical criteria for APLS - had 2 miscarriages after 10 weeks POA, 1 preterm baby at 32 weeks secondary to pre-eclampsia, had DVT 2 years go and now present with 2nd DVT. Even so, she was treated as left leg cellulitis by the GP for almost 1 month before referred to hospital. Her first anticardiolipin antibody detected. So, this is a case of primary APLS.