Sunday, September 4, 2011

CASE 4 Standard Consultation on bilateral leg swelling postpartum (8 mins)

Gemma is a 34yo mother of three, presents to you with bilateral leg swelling.  She is 2 weeks post partum and had a relatively uneventful pregnancy.  Please take a history, ask for examination findings and discuss your management with the examiner.


  1. Hx-
    1. Delivery details, issues during this pregnancy
    2. Onset, progress and nature of bilateral leg swelling
    3. Associated symptoms of legs, such as red/hot/pain legs
    4. Other symptoms, fever, PV bleeding/discharge, pelvic pain, appetite, mobility post delivery, feeding model
    5. Asso symptoms in other systems, such as SOB, cough, chest pain, jaundice, ascites, vision disturbance, headache and neurological symptoms
    6. Medications
    7. PMHx of HTN, heart diseases, liver disease, renal diseases, DVT/PE, varicose veins, arthritis,
    8. Delivery models and complications of previous pregnancies
    9. FHx of DVT/PE or thrombophilia

    1. General appearance, BMI
    2. Vitals – T, P, Bp, RR, SO2
    3. CVS: HS, murmur, apex
    4. Chest: AE, crackles
    5. Abdo/pelvis: tenderness, ascites, liver, spleen, tenderness at kidney area,
    uterus level and tenderness
    6. Legs – type and degree of swelling, ?hot/red/tender, ?Calves , varicose veins
    7. Eyes: VA, vision field, fundi
    8. Neurological examination

    DDX: prolonged sitting/standing, Varicose veins/thrombophlebitis, malnutrition, idiopathic oedema, arthritis, cellulitis, DVT, Thyroid dysfunction, heart/liver/renal failure, malignancy

    1. Urinanalysis, blood sugar and ECG in surgery
    2. hospital admission if history, physical examination and office tests pointing to heart failure or renal failure/nephritic syndrome, or liver failure
    3. Urgent Doppler USS if pointing to DVT
    4. Oral or IV Abs if pointing to cellulitis or endometritis, may need admission depends on severity
    5. Elevate legs, rest, TEDs,

  2. Tricia,

    You have covered it very well here so good work...


    If on the day she was well and....

    1 no fever
    2 bp 150/90 usually "normatensive"
    3 urine protein+++
    4 bilateral swelling but L side is worse
    5 chest clear not in heart failure
    6 abdo nil significant findings....
    7 leg not red but L side calf seems more tender

    AND she does not want to go to hospital yet...

    ??What is your differential at this point and
    ??What is your next step

    Dr Vinh Tran
    MBBS FRACGP Uni of Qld

  3. DDx - nephrotic syndrome/ nephritic syndrome/glomerulonephritis/acute tubular damage, DVT left calf

    Next step - urgent Duplex USS, bed rest, fluid restriction, antihypertensives, diuretics, referral to Nephrologist or at least ask for advice form Nephrologist


  4. Tricia,

    Would you order any pathology test and how urgent?

    Dr Vinh Tran

  5. I would like to order-
    FBC, ELFT, ASOT, CRP, ESR, C3/4,
    24 hour urine protein/cr ratio

  6. BP 170/95 usually 110/60
    Albumin low
    Urine high protein

    What is your diagnosis?
    And how would you manage this further?

    Dr Vinh Tran

  7. Dx:glomerulonephritis -nephritic syndrome
    1. hospital admission
    2. bed rest, daily weighing and fluid chart
    3. restrict salt, protein and fluid intake
    4. antihypertensive or diuretics
    5. penecilline (if ASOT elevated)


  8. Besides, nephritic syndrome what other syndrome is possible?

    And if she is postpartum with "new" hypertension, what else should you consider here?

    Dr Vinh Tran

  9. pre-eclampsia