4 patients with pains in their legs………………

Mr H 65 years of age Type II Diabetes Developed shortness of breath when walking the dog Worse when he is climbing hills and better when he comes down Starts to develop pain in his right leg as well

Medication Ramipril Aspirin Atenolol Metformin Simvastatin

What are the main pathologies here? Which symptoms need to asked when enquiring about his leg pain? Can you explain the indications for each of the medications that are listed Name 3 side effects of each one What is the most likely cause of this mans leg pain? What else can cause similar pain and how do you distinguish this?

Assessment How would you assess this patient on clinical examination? Which features in the history or examination would support your diagnosis He is referred to hospital – which investigations might help

Management What are the priorities for this man’s management? What would you advise relating to his medication? Which factors need to be taken into account relating to managing this man?

MR G Aged 72 Presents with aching pain in right thigh Pain also felt in right groin and into his knee Pain worse when he walks but also keeping him awake at night

Examination What sort of assessment would you make in this man when examining him? Can you explain /demonstrate the examination process to your colleagues? What sort of tests might help you and why might you be doing them?

Test results X ray hip – suggests early arthritic change in right hip ( subchondral sclerosis, loss of joint space and a few osteophytes) Full blood count normal ESR 100 Alkaline Phosphatase raised but ALT normal

What does the x ray report suggest? What are the causes of a high ESR? What might cause the raised ALP? What else might be going on here and how would you follow this up?

Mr K 55 fork lift truck driver Long history of low back pain Develops pain in low back which is causing early morning stiffness Bends down to clip toe nails and develops sudden severe pain in the leg on the left

Clinical assessment What is the most likely pathology here? How would you examine and assess this man clinically? Can you demonstrate the examination to you colleagues? What questions do you need to particularly need to ask this man ?

Tests Normal FBC but slightly raised ESR at 40 and CRP at 12 X ray – Radiologists decline to perform plain film – is this correct? What can be seen on a plain film? What might be a more useful method of assessing this man?

What might you think if the patient is an 80 year old woman?

Red flags What symptoms in the history might suggest that there is something more going on? How can you make a reasonable assessment of this? What actions are open to the primary care doctor when assessing a patient with low back pain

Red flag" and "yellow flag" signs Red flags are possible indicators of serious spinal pathology Thoracic pain Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset 55 years

Yellow flags are psychosocial factors shown to be indicative of long term chronicity and disability A negative attitude that back pain is harmful or potentially severely disabling Fear avoidance behaviour and reduced activity levels An expectation that passive, rather than active, treatment will be beneficial A tendency to depression, low morale, and social withdrawal Social or financial problems

Mrs F Develops pain initially in one then both legs when walking Initially buttocks and thighs then spreads to feet Gets better when sits and leans forward She gets this when walking home at the same place each night

Worse when she goes down hill Last three weeks also noted that her legs get weak when she walks too far

What does this picture suggest? Which of the following tests would you request? Plain lateral x ray lumbar spine MRI scan? Bone scan?

Lumbar canal stenosis Narrowing canal or neural foramina Ischaemia of cord or cauda equina Usually combination disc problem, osteophytes and hypertrophy ligamentum flavum Commonest>60s

Can you think of conditions that might predispose to this problem?

Associated conditions Congenital narrowing of the spinal canal (much less common than degenerative). Degenerative - osteoarthritis.osteoarthritis Hyperparathyroidism.Hyperparathyroidism Paget's disease.Paget's disease Ankylosing spondylitis.Ankylosing spondylitis Cushing's syndrome.Cushing's syndrome Acromegaly.Acromegaly

Questions