WIDI - V2) Leg pain after prolonged travel

V2) Leg pain after prolonged travel

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with lower extremity pain.
Review the DDx considerations in a patient with lower extremity pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with lower extremity pain.

History

A 34-year-old female presents to the emergency department with worsening pain, warmth, and swelling of her left leg following a trans-Atlantic flight. She endorses taking OCPs and a history of recurrent miscarriages due to antiphospholipid syndrome. She denies any shortness of breath or chest pain.

Physical Exam

BP: 118/70, HR 65, RR 18, Temp 36.7, O2 saturation 100%. Pulmonary: Lungs clear to auscultation bilaterally. CV: RRR, no M/R/G, nl S1 & S2. Extremities: LLE: warm and swollen around proximal calf and knee. The patient experiences discomfort in the calf muscles when her foot is dorsiflexed.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Deep venous thrombosis (DVT)

Pulmonary embolism (PE)

Acute limb ischemia

Chronic venous insufficiency

The patient is most likely presenting with a DVT considering the acute onset pain, swelling, and erythema of the left lower extremity with the positive Homan’s sign. She is in a hypercoagulable state secondary to OCP use and antiphospholipid syndrome and therefore at higher risk for a DVT. While a pulmonary embolism can occur secondary to a DVT, it is not likely in this case considering the lack of signs or symptoms.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

This patient requires urgent workup for their suspected DVT.

First Imaging Study

What is the first imaging study you will order?

CTA of the lower extremities.

Venous doppler ultrasound of the lower extremities.

Catheter-guided angiography of the lower extremities.

A venous doppler of the lower extremities can assess for presence of a clot by evaluating venous compressibility and flow. CTA and angiography evaluate the arterial vasculature.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Venous doppler ultrasound of the lower extremities.

There is an occlusive thrombus in the right popliteal vein?

Yes

The right popliteal vein is compressible and demonstrates flow on doppler.

There is an occlusive thrombus in the left popliteal vein?

Yes

The left popliteal vein is not compressible and does not demonstrate flow on doppler secondary to obstruction from clot in the lumen.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

CT of the lower extremities

None

The DVT is demonstrated on this study. No further imaging is required.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Deep venous thrombosis

Pulmonary embolism

Acute limb ischemia

Chronic venous insufficiency

The patient’s history, clinical signs, symptoms, and imaging findings are consistent with a diagnosis of deep venous thrombosis.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient should undergo urgent management.

Assessment and Plan

Please provide your assessment and plan for this patient

The patient is a 34-year-old female presenting with new onset pain, swelling, and erythema of the left lower extremity. Venous doppler confirmed the diagnosis of occlusive DVT in the left popliteal vein. She will require anticoagulation initiation.

Lessons Learned:
- There should be a high clinical suspicion for DVT in patients with components of Virchow’s triad (blood flow stasis, hypercoagulable state, vascular endothelial injury).
- Venous doppler ultrasound, which shows non-compressibility of and lack of flow within the veins, is the gold standard for diagnosing deep venous thromboses.

Socioeconomic Factors: In the US, DVT is most prevalent in African American patients and lowest in Hispanic patients. Insurance status and income level are not associated with the likelihood of admission with a DVT diagnosis. Further research is needed to investigate the cause for these patterns.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator