Acute limb swelling – DVT

Mr. James Thompson, a 52-year-old office worker, presents to the Emergency Department with a 3-day history of right calf pain and swelling. Symptoms began after a 6-hour flight from New York to London. How would you assess this gentleman?

Answer

I would start by taking a focused history of the onset of the limb swelling. I would also ask for a history of trauma, chest pains, pre-syncopal symptoms, and ask for a history of syncope. I would focus on taking a thorough systems review, specifically focusing on the cardiovascular and gastrointestinal system. I would ask about salient past medical history of similar swellings in the past, any family history of similar instances, or any clotting disorders. I would also take a brief social history of his background.

After this, I would do a focused A to E assessment.

(Please detail the A to E and expand specifically on the C and E here)

Examiner

He presents with a progressive unilateral leg swelling and has severe pain that gets worse with walking. On examination, his right calf feels warm and tender to touch and it’s slightly swollen and erythematous compared to the left. He has a BMI of 32 and he is a heavy smoker. What are your differentials and what would you do next?

Answer

These are my top DDx:

• Deep Vein Thrombosis (most likely)
• Cellulitis
• Ruptured Baker’s cyst
• Muscle tear/strain
• Superficial thrombophlebitis

Should mention why DVT is most likely given risk factors and presentation.

I would assess his WELL’s score and, given he has a WELL’s score of 4, I would want to get urgent US Doppler of his legs along with bloods (FBC, U&Es, coagulation).

Calculate score:

• Active cancer (0)
• Paralysis/recent cast (0)
• Bedridden >3 days/surgery (0)
• Localized tenderness along deep veins (+1)
• Entire leg swollen (+1)
• Calf >3cm larger than other side (+1)
• Pitting edema (+1)
• Collateral superficial veins (0)
• Previous DVT (0)
• Alternative diagnosis possible (-2)

Total score = 4 (DVT likely)

Examiner – US confirms a right popliteal vein DVT, what would you do next?

• Immediate anticoagulation
• Discussion of anticoagulation options:
• DOACs (rivaroxaban, apixaban)
• LMWH + warfarin
• Duration of treatment (usually 3-6 months)
• Patient education
• Follow-up arrangements
• Consideration of thrombophilia screening

Examiner – The patient asks about his risk of recurrence. What would you tell him?

Risk factors for recurrence:

• Unprovoked vs provoked
• Male gender
• Obesity
• Residual thrombosis

– Approximately 10% risk at 1 year

– Need for long-term follow-up

– Importance of lifestyle modifications

Examiner – What are the potential complications of DVT that you need to monitor for?

• Pulmonary embolism
• Post-thrombotic syndrome
• Chronic venous insufficiency
• Venous ulceration
• Should mention warning signs and symptoms