Makindo Medical Notes

🩺 OSCE Station – Leg Pain & Swelling

Candidate Instructions 📋

You are a medical student in the Acute Assessment Unit. A 54-year-old woman has presented with a swollen painful left leg. Take a focused history and explain your likely differential diagnoses and initial management plan. You do not need to examine the patient. You have 8 minutes.

Key Learning Points 🔑

• Unilateral painful swelling = think DVT first, but always consider mimics.
• Risk stratification is essential (Wells score).
• Do not miss life-threatening complications (PE 🚨).

History Framework 📝

• Presenting Complaint: Onset, duration, severity of swelling and pain.
• Associated Symptoms: Redness, warmth, tenderness; breathlessness or pleuritic pain (suggests PE).
• Risk Factors: Recent surgery, immobility, travel ✈️, pregnancy, malignancy, past DVT/PE, family history, hormone therapy, smoking.
• PMHx: Cancer, clotting disorders, varicose veins, CKD, heart failure.
• DHx: Anticoagulants, OCP/HRT, aspirin, NSAIDs.
• SHx: Alcohol, smoking, mobility status.

Role-Player Prompts 🎭

• Onset: 3 days of gradual swelling and aching in the left calf.
• Feels warm and tight, worse when walking.
• Recent 8-hour flight from USA.
• No chest pain or breathlessness.
• No past clot history. Mother had a DVT aged 60.
• On combined oral contraceptive pill. Smoker 10/day.
• No recent surgery. No trauma.

Differential Diagnosis ⚖️

• Deep vein thrombosis (DVT) ✅ most likely here.
• Cellulitis (red, hot, painful, systemic upset).
• Baker’s cyst rupture (sudden swelling, calf pain).
• Venous insufficiency (chronic swelling, skin changes).
• Trauma or haematoma.

Investigations 🔬

• Wells score for pre-test probability.
• D-dimer (if Wells score “unlikely”).
• Compression Duplex Ultrasound (gold standard for diagnosis).
• Bloods: FBC, U&E, LFTs, clotting.
• Consider CXR/ECG if PE suspected.

Management 🚑

• Immediate: Assess for haemodynamic stability (rule out PE).
• Anticoagulation: Start apixaban or LMWH if DVT is likely (do not delay pending imaging if Wells ≥ 2).
• Definitive: Confirm with ultrasound within 24h.
• Duration: 3 months if provoked (e.g., surgery, travel), longer if unprovoked or recurrent.
• Adjuncts: Compression stockings (after DVT confirmed, not in acute phase if arterial disease suspected).
• Patient Advice: Stop smoking 🚭, review OCP/HRT, explain risks of PE (SOB, chest pain, collapse).

Examiner’s Marking Guide 📋

• Clarifies site, onset, and associated symptoms.
• Asks about PE features (SOB, chest pain).
• Asks about risk factors (travel, OCP, smoking, PMHx).
• Identifies DVT as most likely, mentions mimics.
• Mentions Wells score, D-dimer, ultrasound.
• Mentions anticoagulation as first-line management.

References 📚

• NICE CKS: DVT
• NICE NG158: VTE