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Old 05-28-2012
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Question left leg pain and swelling...what is her next step? expln plz

A 50-year-old woman is evaluated in the emergency department for a 4-day history of pain, swelling, and erythema of the left leg. There is no history of recent immobilization, cancer, surgery, or deep venous thrombosis.
On physical examination, temperature is 37.7C (100.0F), blood pressure is 132/82 mm Hg, pulse rate is 65/min, and respiration rate is 16/min. Examination of the left leg discloses warmth and circumscribed erythema and tenderness limited to the posterior tibial portion of the leg. The circumference of the left leg is 1 cm greater than the right when measured 10 cm below the tibial tuberosity. Localized tenderness along the distribution of the deep venous system and pitting edema are absent, as are venous varicosities.

Which of the following is the most appropriate next step in diagnosis?

(A) CT of the leg
(B) D-dimer assay
(C) MRI of the leg
(D) Venography
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D ????????
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Quote:
Originally Posted by tyagee View Post
A 50-year-old woman is evaluated in the emergency department for a 4-day history of pain,
swelling, and erythema of the left leg. There is no history of recent immobilization, cancer,
surgery, or deep venous thrombosis.

On physical examination, temperature is 37.7C (100.0F), blood pressure is 132/82 mm Hg,
pulse rate is 65/min, and respiration rate is 16/min. Examination of the left leg discloses
warmth and circumscribed erythema and tenderness limited to the posterior tibial portion of
the leg. The circumference of the left leg is 1 cm greater than the right when measured 10
cm below the tibial tuberosity. Localized tenderness along the distribution of the deep venous
system and pitting edema are absent
, as are venous varicosities.
Which of the following is the most appropriate next step in diagnosis?
(A) CT of the leg
(B) D-dimer assay
(C) MRI of the leg
(D) Venography
(B) D-dimer assay to rule out DVT since she is a low risk patient with low pre-test probability of DVT.

Quote:
Wells score or criteria: (Possible score −2 to 9)
Active cancer (treatment within last 6 months or palliative): +1 point
Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point
Swolen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point
Unilateral pitting edema (in symptomatic leg): +1 point
Previous documented DVT: +1 point
Swelling of entire leg: +1 point
Localized tenderness along the deep venous system: +1 point
Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point
Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point
Alternative diagnosis at least as likely: −2 points[18]
Quote:
D-dimer
D-dimers are a fibrin degradation product, and a positive D-dimer test can result from the sensitive detection of a thrombosis being dissolved by plasmin. A positive test may also result from other conditions.[17] Thus, a positive D-dimer text means further diagnostic testing should be done to determine if a DVT is present, while a negative result can exclude a DVT diagnosis.[17] For suspected first lower extremity DVT in a low-probability situation, the typical next step is to test D-dimer levels with either moderate or high sensitivity.[41] In a moderate-probability scenario, a high-sensitivity D-dimer is recommended over ultrasound imaging (2C),[42] and in high-probability cases D-dimers are to be skipped in favor of diagnostic imaging.[43]

Last edited by Novobiocin; 05-28-2012 at 11:31 AM.
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low pretest probability --> highly sensitive test to rule out (D-dimer)
medium to high pretest probability --> helical CT & compressive leg US --> if negative and the risk is high --> angio

see wells criteria (i dont think they are high yield for the exam; i think the question will be obvious, either clearly low risk or high risk)
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Originally Posted by bisho View Post
low pretest probability --> highly sensitive test to rule out (D-dimer)
medium to high pretest probability --> helical CT & compressive leg US --> if negative and the risk is high --> angio

see wells criteria (i dont think they are high yield for the exam; i think the question will be obvious, either clearly low risk or high risk)
i have a picture mnemonic for wells criteria which makes it breeze easy to remember it? i can share if interested.
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Originally Posted by tyagee View Post
i have a picture mnemonic for wells criteria which makes it breeze easy to remember it? i can share if interested.
Yes please share.
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Originally Posted by tyagee View Post
i have a picture mnemonic for wells criteria which makes it breeze easy to remember it? i can share if interested.
Share the mnemonic plz
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make sure to read the pic from up down

the blue line is femoral vein [deep vein which is painful]
the eye looking in other direction means alternate diagnosis possible
the plaster cast \ can be used for immobilization

the tumor cells\blue dots\cancer is part of wells criteria

the tumor cell is partly removed \ surgery done in this patinet

faint red line was the size of leg prior..so there is diffuse leg swelling

the circle says its 3 cm big

the foot is thick...for edema

lastly, the faint blue lines on foot means collateral veins

ho!!!

do you like it? lemme know? i have more of such things..love making them
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left leg pain and swelling...what is her next step? expln plz-wells-criteria-dvt.jpg  
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