General Surgery Station 6

Setting:

You are a Foundation Year doctor working in the GP. This patient has presented with leg pain.

Leanne Rowley

Tasks:

1. Take a focused history from the patient.

2. State your differential diagnosis to the examiner.

3. State any investigations you would like to carry out to the examiner.

4. Please interpret the investigation provided to the examiner.

Briefing

Diagnosis: Peripheral vascular disease presenting with lower leg pain.
You are Leanne Rowley a 71 year old female.
You have presented to your GP practice with leg pain.

Appearance and Behaviour

You should appear comfortable at rest with no pain at time of questioning, however you are getting frustrated that this pain is limiting your mobility.

Opening statement

“I’ve been getting this terrible pain in my leg while I’m walking. ”

Information to Give Freely

Everytime I go for a walk, my leg starts hurting. It would only happen now and then initially but now it happens every time I walk.

Presenting Complaint

Site – left calf
Onset – started a couple of months ago
Character – cramping/achey pain
Radiation – nil.
Associated symptoms – No chest pain or shortness of breath. No leg swelling or erythema. No pain in buttocks or thighs. You’ve noticed you’ve lost some hair on the left calf/shin and the skin is quite shiny.
Timing – it’s been happening with increasing frequency.
Exacerbating/relieving factors – starts when walking and is worse up hills/stairs. It goes away with rest in about 5-10 minutes. NO pain at rest.
Severity – Initially 3/10, now usually 7-8/10. It’s starting to affect your mobility - before you could walk indefinitely without much issue, now you start noticing the pain after a couple of minutes of walking (about 500m)

Past Medical History

Previous episodes: No similar episodes before this started a month ago
Other medical conditions - Hypertension, type 2 DM (with poor control), angina
Previous surgeries - nil

Drug History

Prescribed - GTN for angina, Insulin for Diabetes (Lantus injection every night), ramipril, amlodipine and bendroflumethiazide for hypertension.
Over the counter - Nil
Allergies - NKDA

Family History

Your aunt had a blood clot in her leg.

Social History

Smoking history - smoking 25 a day for the last 50 years, tried to cut down recently and are receiving support from GP.
Alcohol - nil
Home - live alone in a bungalow, your children live nearby and are supportive.
Normally fully independent, although recently you have found that your legs are giving you trouble when you walk around the supermarket.

Systems Review

General/red flags - no fever, no weight loss, no night sweats
Neuro - Nil
Resp - No shortness of breath, no hemoptysis.
Cardio - Occasionally have chest pain relieved by GTN spray - you aren’t concerned, it’s just part of your angina. No leg swelling or waking up feeling breathless at night.
GI - Nil
GU - Nil
Joints - No joint pain, no swelling or redness.
Skin- left leg hairless, shiny, you have noticed the left leg is cold to touch at the toes.

Ideas / Concerns / Expectation

Ideas - “Could it be arthritis? I know a few friends have had it”
Concerns - “It will keep getting worse until I can’t walk any more”
Expectations - “Some good pain relief to let me walk further”

Discussion / Questions

Nil