A 54-year-old woman comes to the office due to 2 days of dull, aching pain and mild swelling of the left leg. The symptoms began after a 12-hour nonstop flight. The patient has had no shortness of breath, chest pain, or fever. She has been able to ambulate and perform daily activities despite the discomfort. Medical history includes hypertension and hyperlipidemia. She has smoked a pack of cigarettes daily for the last 30 years but does not use alcohol or injection drugs. The patient has no drug allergies. She works in a law firm.
Vital signs are within normal limits. BMI is 31 kg/m². Heart sounds are normal, with no murmurs. The lungs are clear to auscultation. The left calf is mildly tender to palpation, with increased circumference compared to the right. The remainder of the physical examination is normal.
Laboratory results of blood cell counts, serum chemistry, and coagulation studies are within normal limits. Lower extremity venous Doppler ultrasonography shows an occluding thrombus in the left popliteal vein. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

This patient with a provoked deep vein thrombosis (DVT) and minimal risk factors for complications should be considered for outpatient anticoagulation. Historically, most patients with DVT have been hospitalized for initiation of anticoagulation; however, the advent of easily administered rapid-acting anticoagulation (ie, novel direct-acting oral agents) has made outpatient therapy an increasingly important management option. Outpatient management should be considered for patients who meet all of the following criteria: Hemodynamic stabilityLow risk of bleedingNormal kidney functionReliable social environment for administration of anticoagulation Hemodynamic stability Low risk of bleeding Normal kidney function Reliable social environment for administration of anticoagulation Patients with a large clot burden (eg, iliofemoral DVT) or concomitant pulmonary embolism should not be considered for outpatient management. In addition, comorbid conditions such as decompensated heart failure or malignancy often preclude initial outpatient management. Rivaroxaban or apixaban can be initiated as monotherapy without bridging and are the drugs of choice for outpatient management. Other potential regimens include warfarin, dabigatran, or edoxaban accompanied by bridging with low-molecular-weight heparin. (Choice A) Initial inpatient management should be reserved for patients that fail to meet the inclusion criteria for outpatient management of DVT or have high-risk features (eg, malignancy). (Choice B) Due to the availability of an antidote and the rapid cessation of action, admission and initiation of unfractionated heparin is now used most commonly for patients with an increased risk of bleeding. In addition, patients with phlegmasia cerulea dolens (massive iliofemoral DVT) can be treated with heparin while awaiting more definitive therapy such as thrombolysis or thrombectomy. (Choice C) The direct thrombin inhibitor dabigatran is less appropriate for outpatient management of DVT because, based on current evidence, 5 days of heparin bridging is recommended at initiation. Repeat ultrasonography at 2 weeks is not indicated unless there is clinical concern for clot extension. (Choice E) Due to the low likelihood of embolization, supportive care alone is often appropriate for patients with superficial thrombophlebitis or distal (below-knee) thrombus. However, proximal DVT requires anticoagulation treatment. Educational objective: Outpatient therapy is an important management option for patients with deep vein thrombosis and should be considered for those who are hemodynamically stable with a low risk of bleeding, normal renal function, and stable social environment. __________ References: Diagnosis and treatment of deep-vein thrombosis. (http://www.ncbi.nlm.nih.gov/pubmed/17060659) Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315257)

A 54-Year-Old Woman Comes to the Office Due to 2