by Barry J. Sheridan, D.O., James A. Pfaff, M.D., Eric Johnson, R.N., BSN
CHIEF COMPLAINT:
Leg swelling and discoloration.
HISTORY OF PRESENT ILLNESS:
A 72 year old white woman presents to the ED complaining of left- leg discoloration, pain, and swelling which developed over several hours. The patient has a history of bilateral leg swelling of 2-3 months' duration, for which she had been wearing compression stockings. She noticed some mild reddish-blue discoloration at the top of her left stocking associated with a burning-itching sensation. She then removed the stockings and noticed that a large area of her left upper leg was reddish-blue with small blisters and markedly more swollen. The patient denies any fever, trauma, or bites. Doppler ultrasonography of her left leg two weeks prior had yielded normal results. Past medical history is significant for ankylosing spondylitis, hypertension, and hypothyroidism. Medications include propanolol, levothyroxine, conjugated estrogen, medroxyprogesterone acetate, ferrous sulfate, flurbiprofen, and calcium supplements.
PHYSICAL EXAMINATION:
The patient is alert, appears pale and anxious, and is in moderate discomfort from pain in her left leg. Her vital signs are temperature 36 degrees C (rectal), pulse 73 beats/min, blood pressure 113/59 torr, and respirations 18 breaths/minute. The results of her HEENT, cardiovascular, respiratory, abdominal, and neurological exams are normal. Her left leg is tender to palpation without crepitus. Pitting edema extends the entire length of the leg with a reddish- blue discoloration. Numerous small vesicles are also noted with three, 3- 5 cm hemorrhagic bullae on the medial thigh. See figure 1. The patient also complained of a burning-itching like pain in her left leg with palpation. Neurological exam is normal in the extremity. Pulses are normal in the affected leg, however capillary refill time is three seconds. No adenopathy is present.
LABORATORY:
The white blood cell count is 8,700 with a normal differential, a Hb of 10.7 g/L, a hematocrit of 32.8%, and 168,000 platelets. The level of sodium is 130 mmol/L, potassium 3.5 mmol/L, chloride 101 mmol/L, carbon dioxide 14 mmol/L. Glucose, BUN, and creatinine levels are normal. Prothrombin time is 23.4 seconds, and partial thromboplastin time is 29.8 seconds. Fibrinogen and fibrin split products are normal. Chest, left leg x-rays and repeat left leg Doppler ultrasonogram are normal.
From Academic Emergency Medicine 1(6):562-563 1994 November/December
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