My legs are Swole OSCE by Adam

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You are an emergency consultant in tertiary emergency department and your intern comes to asking for guidance on how to approach a patient she has just seen.
The patient in question is a 55F with painless bilateral leg swelling which has been present for 3 weeks. Her obs are normal, She has was started on amlodipine 4 weeks ago, She has never had a malignancy, no known heart failure, renal or liver disease. No other meds. Non drinker. Works in an office. The patient wants to go home.

Instructions for the candidate

Please talk the Intern through a practical approach to assessment, investigation and management of this patient.
Please focus on the differential diagnosis and the investigations.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Scholarship and Teaching
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You have little knowledge about oedema.
You're differential consists of a DVT and CHF.
You haven't requested any investigations
The patient is well with normal vitals, just isolated bilateral lower limb oedema

For the examiner

Consider a broad differential:
1. Localised disease:
- Bilateral dvt, bilateral lymphoedema ( not impossible, but less likely), depedent oedema ( elderly, obese, prolonged standing), pelvic mass ( Ovarian, metastatic prostate), idiopathic ( Females 20-40)
2. Systemic disease:
CHF, RHF/Cor pulmonale, Liver disease, Renal disease ( glomerulonephritidies), Myxoedema, Pre-eclampsia
3. Drug induced:
Antihypertensives (Dihydropyridines, alpha blockers) Anagesics (NSAIDs, Gabapentin, pregabalin), Endocrine (sex hormones- progesterone, oestrogen, testosterone, tamoxifen. Glucocorticoids, mineralocorticoids)

Alternate classifications could include Acute vs Chronic causes. Or Pathophysiological- causes of increased capillary hydrostatic pressure and causes of Decreased capillary oncotic pressure.

HxPC: Timing, ? painful, ?relieved at night (dependent), systemic symptoms, recent infections ( nephrotic), weight loss or gain, pregnancy
PMHx: Heart, renal and liver disease. malignancy and surgical and non surgical Rx (radiotherapy)
DHx: As above, and timing of commencement
Shx: sedentary legs crossed in a chair vs prolonged standing (army), ETOH intake, recreational drug use (meth heart)

Examination:
1. CHF- Hypertensive, 3rd heart sound, elevated JVP, hepatojug reflux, palpable liver pulmonary oedema, anaemia
2. Liver disease- Ascites, shifting dullness, periheral stigmata
2. Endocrine- Hypothermic, obesity, thinning hair, bruising
3. Lymphoedema - Stemmer sign, unable to pinch skin at the base of digits
4. Chronic venous insufficiency: Dermatitis, inverse champagne bottle, talengiectasias, varicosities, venous ulcers (medial, shallow, grannulation tissue, distribution of saphenous

Investigations:
Bedside- Urinary protein. ECG- LVS/RVS, prior ischaemia, cardiomegaly. BSL
Path:
FBE - anaemia, platelet count
U&E- Renal failure (acute/chronic)
LFT- Liver failure
Coagulation/ albumin- liver synthetic function
BHcg
BNP
TFTs

Imaging:
CXR
US Doppler
Echo

Pelvic US/ CT abdo pelvis
- Especially other investigations don't yield a cause and >50years

Treatment options:
Pharmacological and non pharm
Medication cessation
Compression bandage and leg elevation
Graded compression and physio.
Weight loss
Salt restriction.
Management of underlying cause

Domains Assessment Objectives

Medical Expertise

Prioritisation And Decision Making

Scholarship and Teaching

Other Assessment Notes


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