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Old 06-21-2011
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Question Tx of DVT in 31-year-old woman?

A 31-year-old woman presents to the emergency department complaining of a swollen leg. The swelling began about 1 hour ago and is painful. She has no history of serious illness or recent trauma. She has just arrived after a 15-hour bus ride for a visit with relatives. She has a 15-packs-per-year smoking history and takes birth control pills. She takes no other medications. On examination, the right thigh is swollen compared with the left. In addition, the right leg is red and warm to the touch. There is no sign of trauma. Passive dorsiflexion of the right foot causes pain. No cords are palpable. Which of the following is the next step in management of this patient?

Answer Choices Correct answer Your answer
A. Begin intravenous (IV) heparin
B. Begin IV antibiotics and obtain radiographs of the affected limb
C. Begin oral warfarin
D. Obtain an ultrasound of the affected leg
E. Order immediate vascular surgery
Explanation
Option A (Begin intravenous [IV] heparin) is correct. This patient has deep venous thrombosis until proven otherwise. The patient is at risk of a potentially fatal pulmonary embolism at any time. Immediate intravenous heparin therapy is indicated on clinical grounds alone.

Option B (Begin IV antibiotics and obtain radiographs of the affected limb) is incorrect. This could possibly be a cellulitis or other infectious process, but the clinical picture is classic for deep venous thrombosis. The patient requires immediate intravenous heparin.

Option C (Begin oral warfarin) is incorrect. This patient has deep venous thrombosis until proven otherwise and is at risk of a potentially fatal pulmonary embolism at any time. Anticoagulant effects of warfarin do not reach effective levels for hours to days. Immediate anticoagulation with intravenous heparin is required. Warfarin should not be started until the diagnosis of deep venous thrombosis is confirmed.

Option D (Obtain an ultrasound of the affected leg) is incorrect. This patient has deep venous thrombosis until proven otherwise and is at risk of a potentially fatal pulmonary embolism at any time. An acute pulmonary embolism is one of the few conditions that can almost instantly kill a healthy young adult. Anticoagulant therapy with intravenous heparin must be started at once. Waiting to confirm the diagnosis could prove disastrous.

Option E (Order immediate vascular surgery) is incorrect. This is not the clinical presentation of an arterial occlusion. Further prompt diagnostic evaluation can proceed to evaluate this possibility or other conditions requiring surgery, but the first step is to start intravenous heparin.

i choose Option D (Obtain an ultrasound of the affected leg)
we usually dx dvt 1st then treat it am i right according to MTB
as a rule PE we rx then ix but DVT we Ix after confirm Dx we Rx

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