Left leg pain and edema


• Acetaminophen and codeine prn pain Disposition

• Discharged

• Follow up PCP in 3 days


Brock Daniels, MD Yale School of Medicine

David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


Andy Barnett, MD Assistant Professor of Emergency Medicine Oregon Health and Science University


• Venous stasis

Differential Diagnosis

• Venous stasis

• Deep vein thrombosis

• Osteomyelitis

• Cellulitis

• Necrotizing fascitis

• Gas gangrene

• Erysipelas

• Abscess

Patient Workup

• X-rays – revealed osteopenia, no fracture

• Doppler US – neg for DVT

• CBC – nl

• CMP – nl

• BNP – 195 (H)

• PT – 22.8 (H)


Key Points

• Deep vein thrombosis should be considered in patients with unilateral lower extremity swelling and risk factors for DVT. Ultrasound and/or high sensitivity D-dimer are appropriate initial tests.

• The Modified Wells and Geneva scores are well-validated risk stratification tools.

• Chronic venous insufficiency (CVI) due to incompetent valves and venous hypertension may be a complication of DVT, or may be a predisposing factor for DVT. Patients with CVI are at risk of venous stasis ulcers and skin infections.

• Venous stasis ulcers are typically located over bony prominences, have a pink, wet base with irregular margins, contain granulation tissue and are surrounded by blue-black pigmented skin associated with venous stasis.

• The lower extremities are the most common site for soft tissue infections and are more common in patients with CVI, diabetes and peripheral arterial disease.

• Cellulitis and erysipelas differ in the depth of involved dermal layers. Cellulitis is more indolent and extends into the deep dermis and fat.

• Large, deep ulcers, or those with exposed bone, should raise suspicion for osteomyelitis. ESR and CRP may be elevated and plain films may show cortical erosion or periosteal reaction.

Editor’s Notes

In this as with most of our cases – the clips are short and do not capture the entire history or exam, or all of the findings that led to the diagnosis. In this case, the videographer was not the physician caring for this patient, so he did not take off the bandage during the interview. The treating physician did remove the bandage in an un-taped portion of the exam, which helped clinch the diagnosis. -Dr. David Spiro Proper translation is often critical to understanding the history of illness. This diagnosis is very much about history; if there has been no change in weeks, then CVI is appropriate. If the exam changed recently, then an infection or vascular occlusion moves up on the differential.

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