Acute leg pain in a 73-year-old man

Problem 24 Acute leg pain in a 73-year-old man



Robert Fitridge



You are relaxing in a comfortable chair in the doctors’ mess, looking at the clock ticking towards the end of your shift when your thoughts are interrupted by a call from the ward.

The nurse would like you to see a 73-year-old man who is complaining of sudden-onset acute severe pain in his left leg. Two days earlier he had been admitted to hospital with an anterior myocardial infarction.


Q.1


What diagnoses go through your head as you head for the ward?


When you see the patient, you find him distressed with pain. He tells you the pain in his left leg came on abruptly about 40 minutes ago. The leg now feels numb and he cannot move it. He gives no prior history of claudication.


His blood pressure is 130/80 mmHg and his pulse rate 100 (irregularly irregular). Examination of the chest is unremarkable. There are no abnormalities in his abdomen. His femoral pulses are of good volume, the pulses in his right leg can all be felt. There are no pulses to be felt below the groin on the left side. The left leg is not swollen, but pale and cool to the touch.



Q.2


What do you think has happened? What further information would you like?


You are handed his in-patient notes. He had presented with 7 hours of chest pain. Work-up showed an acute anterior myocardial infarction. As his pain had subsided and he had developed Q waves in the anterior leads, he was not given any thrombolytic therapy.


He was immediately given oral aspirin and betablockers before being transferred for close monitoring in the coronary care unit. He remained there for 2 days before moving to the general ward. Now, 4 days since his admission, he has been slowly mobilizing. He was initially prescribed subcutaneous low molecular weight heparin, but you note on the drug chart that this was not continued on the ward since returning from coronary care.


His myocardial infarction was complicated by atrial fibrillation, with a rapid ventricular response rate on day 1. He had no ventricular arrhythmias and was treated with digoxin resulting in good rate control. He does not have any other significant past medical history.



Q.3


What would you like to do now?


An investigation is performed. One of the results is shown in Figure 24.1.


image

Figure 24.1



Q.4


What is this investigation? What does it show?



Q.5


What would you like to do now?


The patient underwent thrombolysis of the embolus radiologically using the ‘pulse-spray’ technique that often results in rapid clot lysis. Standard thrombolytic techniques would take 4–20 hours to achieve clot dissolution, and it was thought this patient’s leg was unlikely to be viable if revascularization took this length of time. The ‘pulse-spray’ technique is much more rapid. After 1 hour of urokinase pulsing, the angiogram was repeated (Figures 24.2 and 24.3).


image

Figure 24.2


image

Figure 24.3



Q.6


What do these new angiograms show?

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Acute leg pain in a 73-year-old man

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