Case 58 – update 1

Thanks for the contributions so far.

 

We have established that our patient is a 37 year old female and has presented to her general practitioner with a swollen left leg. She had a recent car journey of 90 minutes but the feeling was this was not enough to cause a DVT. She has a history of a great aunt having a DVT but this may have been post surgery. She has not had any recent immobility and is not on any medications (including hormonal therapy).

 

The differential diagnosis of a swollen/painful  leg may include:

  • Deep vein thrombosis
  • Muscular injury
  • Ruptured Baker’s cyst
  • Lymphoedema or other obstruction of the lymph node e.g. lymphoma/cancer
  • Infection e.g. cellulitis
  • Bleed (often see these in acquired haemophilia)

 

Our patient has had no injuries and the leg does not look infected. A DVT is suspected and a Wells’ score is done. This is used in the diagnostic pathway for DVT and includes:

 

Wells DVT

 

In our patient the entire leg was swollen, but there was no active cancer, no recent immobility, there was no tenderness over the deep veins and the calf was 2.5cm larger on the affected side without pitting oedema. Therefore her Well’s score is 1.

 

Questions:

  • You have a patient with a Well’s score of one. What’s your next line of investigation?
  • If the score was two what would you do next?
  • How would your management change if she was pregnant?

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