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Cold, painful, pale, pulseless leg/foot

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Acute Limb Ischaemia

  • Embolism: Sudden onset, severe pain, history of atrial fibrillation, recent myocardial infarction, or a known source of emboli
  • Thrombosis: Gradual worsening of symptoms in a patient with a history of peripheral artery disease (PAD), often in the setting of atherosclerosis
  • Trauma: History of injury to the limb, may be associated with fractures or direct vascular damage
  • Aortic dissection: Severe, tearing chest or back pain radiating to the abdomen, associated with reduced or absent pulses in the lower limbs

Chronic Limb Ischaemia

  • Peripheral artery disease (PAD): Gradual onset of intermittent claudication, relieved by rest, history of smoking, diabetes, or hyperlipidemia
  • Buerger’s disease (thromboangiitis obliterans): Strongly associated with smoking, affects young men, presents with claudication, rest pain, and ischemic ulcers
  • Raynaud’s phenomenon: Episodic color changes in fingers/toes (white-blue-red), triggered by cold or stress, usually resolves with warming

Venous Causes

  • Deep vein thrombosis (DVT): Swollen, painful leg with a possible history of immobility, recent surgery, or thrombophilia; may lead to post-thrombotic syndrome
  • Phlegmasia cerulea dolens: Severe form of DVT leading to venous gangrene, characterized by a swollen, cyanotic, painful leg

Neurogenic and Other Causes

  • Lumbar spinal stenosis: Pain and numbness in legs, worsened by walking (neurogenic claudication), relieved by sitting or leaning forward
  • Complex regional pain syndrome (CRPS): Chronic pain condition, often following an injury, associated with autonomic dysregulation, leading to color and temperature changes in the limb
  • Frostbite: History of exposure to extreme cold, pale and cold extremities, blisters, possible necrosis
  • Vasculitis: Systemic symptoms like fever, weight loss, palpable purpura, and possible multi-organ involvement

Key Points in History 🥼

Onset and Duration

  • Sudden vs gradual onset: Sudden onset of symptoms suggests acute limb ischemia (e.g., embolism, thrombosis), while a gradual onset may suggest chronic conditions (e.g., PAD)
  • Duration: Acute limb ischemia is a surgical emergency, whereas chronic symptoms might indicate long-standing peripheral vascular disease
  • Intermittent vs constant pain: Intermittent claudication suggests PAD, while constant pain, especially at rest, suggests critical limb ischemia

Associated Symptoms

  • Paralysis and paraesthesia: These symptoms, along with pain, indicate limb-threatening ischemia (the 6 Ps: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, and Poikilothermia).
  • Systemic symptoms: Fever, weight loss, and fatigue may suggest vasculitis or other systemic inflammatory conditions.
  • History of embolic events: Previous episodes of embolism, atrial fibrillation, or endocarditis increase the likelihood of an embolic cause.

Background

  • Past medical history: Key conditions include diabetes, hypertension, hyperlipidemia, atrial fibrillation, and previous vascular events (e.g., stroke, myocardial infarction)
  • Drug history: Anticoagulants or antiplatelets, recent changes in medication, use of vasoconstrictive agents, or history of illicit drug use (e.g., cocaine)
  • Family history: Family history of vascular diseases or thromboembolic conditions
  • Social history: Smoking (strongly associated with PAD and Buerger’s disease), alcohol use, occupation (e.g., prolonged standing), and recreational drug use

Possible Investigations 🌡️

Bedside Tests

  • Ankle-brachial pressure index (ABPI): Used to assess the severity of PAD; an ABPI <0.9 indicates significant arterial disease
  • Doppler ultrasound: To assess blood flow and detect occlusions or stenosis in the arteries
  • Capillary refill time: Prolonged refill (>2 seconds) may suggest poor perfusion
  • Pulse examination: Assess for reduced or absent pulses, especially in the femoral, popliteal, and pedal arteries

Blood Tests

  • Full blood count: To assess for anemia, infection, or polycythemia (which can increase risk of thrombosis)
  • Coagulation profile: To check for clotting abnormalities, especially in patients on anticoagulants
  • Urea and electrolytes: To assess renal function, which can be affected by shock or systemic illness
  • D-dimer: May be elevated in DVT or embolism, though not specific
  • Lactate: Elevated levels may indicate tissue ischemia and hypoperfusion

Imaging

  • Duplex ultrasound: First-line imaging for assessing arterial blood flow and identifying occlusions in PAD
  • CT angiography: Provides detailed imaging of the arterial system, useful for planning revascularization procedures
  • MR angiography: An alternative to CT angiography, particularly useful in patients with contrast allergies or renal impairment
  • Conventional angiography: Gold standard for detailed vascular imaging, often combined with interventional procedures (e.g., angioplasty)
  • X-ray: May be useful in cases of trauma to identify fractures or foreign bodies that may have caused vascular injury

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Cardiovascular