Swollen leg exam

Examination of the unilaterally swollen leg

Differential Diagnosis

• DVT
• cellulitis, myositis, fascitis
• venous obstruction due to a tumor
• hematomas
• muscle injury
• compartment syndrome

ABC's and initial assessment

• extreme pain → compartment syndrome

Vitals

• Pulmonary embolism: SOB,↑ HR, ↑ RR, ↓ O2 sat → PE
• cellulitis → fever

Well's Score

History

• active cancer (+ 1)
• paralysis, or recent cast (+ 1)
• recent immobilization x > 3 days, major surgery (+ 1)
• history of clots, DVT (+1)

• pain - severity
• recent trauma (sports, blunt) → hematoma, muscle injury

Inspection

• swelling of entire leg (+ 1)
• collateral superficial veins (+ 1)

• erythema, sharp demarcated border → cellulitis

Palpation

• tenderness along deep veins (+ 1)
• ≥ 3 cm increase in calf circumference vs. other leg (+ 1)
• pitting edema (+ 1)

• compression of calve against the tibia → ↑↑ pain
• warmth
• distal pulses, capillary refill → ↓ in longstanding arterial disease
• passive range of motion of the toes or ankle → ↑pain in compartment syndrome

Assessment

• likelihood of alternative diagnosis (- 2)

Well’s score

• > 3 = high probability of DVT
• 1 - 2 = moderate
• 0 = low

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