A 45-year-old woman comes to the emergency department with left leg pain and swelling that has worsened over the last 2 days. The patient has no fevers, chills, dyspnea, or chest pain and has had no trauma to the left leg. Her medical history includes rheumatoid arthritis and gastroesophageal reflux disease, for which she takes low-dose methotrexate, folic acid, and omeprazole. The patient has smoked a pack of cigarettes daily for 10 years and does not consume alcohol. Temperature is 37 C (98.6 F), blood pressure is 140/80 mm Hg, pulse is 70/min, and respirations are 14/min. BMI is 30 kg/m². The left leg is swollen (4 cm) compared to the right and is warm and tender on palpation. Pitting edema is present. Her legs are shown in the image below. Which of the following is the most appropriate next step in management of this patient?

Question

A 45-year-old woman comes to the emergency department with left leg pain and swelling that has worsened over the last 2 days. The patient has no fevers, chills, dyspnea, or chest pain and has had no trauma to the left leg. Her medical history includes rheumatoid arthritis and gastroesophageal reflux disease, for which she takes low-dose methotrexate, folic acid, and omeprazole. The patient has smoked a pack of cigarettes daily for 10 years and does not consume alcohol. Temperature is 37 C (98.6 F), blood pressure is 140/80 mm Hg, pulse is 70/min, and respirations are 14/min. BMI is 30 kg/m². The left leg is swollen (>4 cm) compared to the right and is warm and tender on palpation. Pitting edema is present. Her legs are shown in the image below. Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d432_f98a_bc81_3f081224f4ea_MD0003_00 This patient with left leg pain and marked asymmetric swelling likely has a deep venous thrombosis (DVT). Rheumatoid arthritis (RA) itself is a risk factor, regardless of whether or not it is associated with immobilization. Other common risk factors include family history of DVT, trauma, hypercoagulable state (eg, underlying malignancy), and medications (eg, oral contraceptives). The diagnosis of DVT is based on history and physical examination findings combined with laboratory results and imaging. The modified Wells score is a widely used risk assessment tool for DVT. Patients with a score ≥2 (eg, pitting edema, calf swelling >3 cm compared to the other leg) are more likely to have DVT. In such patients, compression ultrasonography is the preferred initial test as it can be performed quickly in most emergency departments. Patients with clinical evidence of pulmonary embolus (PE) should be started on anticoagulation if there are no contraindications (eg, active bleeding) while undergoing diagnostic evaluation. Those with features of DVT only, as in this case, should have the diagnosis confirmed prior to starting anticoagulation as anticoagulation itself has risks (Choice F). (Choice A) Anticoagulation is the preferred treatment for patients with confirmed DVT. Aspirin is used in patients with peripheral artery disease, which can cause atypical leg pain (without swelling or warmth) that is often bilateral and exacerbated by exertion. (Choice B) Blood cultures and empiric antibiotic therapy would be appropriate in patients with cellulitis, but such patients would generally also have fever (or other systemic symptoms), extremity redness, and an elevated white blood cell count. Marked asymmetric swelling is also more suggestive of a DVT. cellulitis (Choice C) Chest CT angiogram is recommended for patients with suspected PE, but this patient has no findings to suggest PE (eg, pleuritic chest pain, dyspnea, tachycardia, tachypnea). (Choice E) In patients with low pretest probability based on the Wells score, a negative D-dimer is useful for excluding DVT. However, D-dimer levels are not specific for DVT, and an elevated level alone is not sufficient to establish the diagnosis. In patients with moderate or high pretest probability (as in this patient), compression ultrasonography is the best next step. Educational objective: Noninvasive evaluation with compression ultrasonography is recommended as an initial test in patients with moderate or high probability of deep venous thrombosis. References: Diagnosis of deep venous thrombosis and pulmonary embolism. (http://www.ncbi.nlm.nih.gov/pubmed/23157144)

A 45-Year-Old Woman Comes to the Emergency Department with Left