Leg Pain

Medical History

[accordion][accordion_item title=”History of Present Illness”]The patient is an [AGE] years old [fe]male presenting to the ED complaining of [right-sided] leg pain that since [TIME]. There is [no] associated swelling of the leg. The distribution of the pain is [not] along the deep vein distribution. The onset of pain was [not] abrupt. [Patient denies shortness of breath or fever.] [The pain was exquisitely tender.] [The patient denies any history of heart disease, blood clots or cancer.] [Patient denies any history of surgery or trauma in the last month.] [Patient denies being mostly bed-bound over the last few days and denies any recent travel.][/accordion_item][accordion_item title=”Physical Exam”]Normal Exam

General: [appear comfortable on stretcher.];
HEENT: [mucous membranes moist];
Cardiovascular: [Regular rate and rhythm];
Respiratory: [Symmetric and clear breath sounds];
Gastrointestinal: [Soft, nontender, nondistended in all quadrants.];
Musculoskeletal: [Full active and passive range of motion in the lower extremities.] [No associated ankle swelling.] [Negative Homan’s sign] [No tenderness to palpation along deep vein distribution.][Distal pulses intact and equal bilaterally];
Skin: [No rash];
Neurologic: [The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric.];

DVT Exam

General: [appear comfortable on stretcher.];
HEENT: [mucous membranes moist];
Cardiovascular: [Regular rate and rhythm];
Respiratory: [Symmetric and clear breath sounds];
Gastrointestinal: [Soft, nontender, nondistended in all quadrants.];
Musculoskeletal:[Limited range of motion on affected extremity due to pain.] [Associated swelling on affected leg.] [Positive Homan’s sign] [Tenderness to palpation along deep vein distribution.][Distal pulses intact and equal bilaterally];
Skin: [No rash];
Neurologic: [The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric.];[/accordion_item][/accordion]

Medical Decision Making

[accordion][accordion_item title=”Initial Evaluation and Diagnostics”]Patient presents with [unilateral] leg pain. I have considered life and limb threatening causes of leg pain, which include an occult fracture, deep venous thrombosis, and arterial thromboembolism.

Trauma

  • Because the patient’s history and physical exam suggest a possible traumatic injury, I obtained X-rays of the [right] leg which demonstrated no acute fractures or subluxations.

No DVT  testing

  • Patient’s symptoms is not consistent with DVT, as they have no history of malignancy, no history of DVT, have no recent immobilization, no difference in calf diameter per my physical exam, no recent surgery, and no calf swelling or pain, which virtually rules out the diagnosis.

DVT Testing

  • I am unable to exclude the diagnosis of a DVT from my differential diagnosis with my history and physical exam alone. Based on the Well’s criteria and my clinical gestalt, the patient is risk stratified as [low][moderate][high] risk to have a clinically significant DVT.
  • Negative testing
    • Therefore, a [d-dimer][lower extremity doppler ultrasound] was ordered and resulted to be negative, thereby ruling out the diagnosis of DVT.
  • Positive d-dimer, negative testing
    • Therefore, a d-dimer was ordered and resulted to be positive. This was followed-up with a lower extremity doppler ultrasound, which resulted to be negative, thereby ruling out the diagnosis of DVT.
  • Positive d-dimer, positive testing
    • Therefore, a d-dimer was ordered and resulted to be positive. This was followed-up with a lower extremity doppler ultrasound, which resulted to be positive for DVT in the [LOCATION].
  • No d-dimer, positive testing
    • A lower extremity doppler ultrasound was positive for a DVT in [LOCATION].

Coagulation studies

  • INR, and PTT was ordered to aid in adjustment of anticoagulation dosing in the event that it is required.
Basic labs
  • Due to my inability to exclude the possibility of an acute illness as a contributing factor to the patient’s clinical presentation, I obtained a complete blood count, electrolyte panel, and renal function test studies, which demonstrated no leukocytosis, no gross electrolyte abnormalities, and no significant changes from baseline renal function.
ESR and CRP
  • Due to my inability to exclude the diagnosis of myositis from my differential, I decided to obtain ESR and CRP, which was within normal limits, and virtually ruling out the diagnosis.
MRI
  • Due to my inability to exclude the diagnosis of myopathy, myelitis, or cauda equina from my differential, I decided to obtain an MRI of the spine, which was negative for gross abnormalities.

CTA of the lower extremities

  • Due to my inability to exclude the diagnosis of an arterial embolism from my differential, I decided to obtain a CTA of the lower extremity, which was negative for clot.

[/accordion_item][accordion_item title=”DVT”]LMWH

  • Because there is no renal insufficiency or other contraindications, fixed-dose subcutaneous low-molecular-weight heparin is the preferred treatment over UFH. I have initiated treatment with a 2mg/kg dose of subcutaneous low molecular weight heparin.

Warfarin

  • I have initiated treatment with PO warfarin at 10mg concurrently.

Renal insufficiency

  • Because there is signs of renal insufficiency, LMWH is contraindicated in this patient. Therefore, I have initiated treatment with unfractionated heparin at 80U/kg of total body weight.

Rivaroxaban

  • I have discussed with the patient the benefits and risk of different treatment options, namely low molecular weight heparin and rivaroxaban, and they expressed a strong preference in undergoing treatment through oral agents. As rivaroxaban demonstrated non-inferior rates of recurrent VTE and decreased rates of major bleeding in pooled analysis compared with LMWH/VKA therapy, it is a reasonable option for outpatient therapy. I have warned them of the risks of bleeding while on these agents and the lack of effective reversal agents should they experience a life-threatening bleed. I have initiated treatment with PO rivaroxaban 15mg twice daily for 21 days.

Distal vein DVT

  • ACCP guideline caution that routine treatment of distal calf veins is not warranted, as the risk of bleeding from anticoagulation can outweigh the relatively low risk of propagation or extension into a clinically significant VTE. Only serial imaging of the lower extremity for the first two weeks is recommended in patients with isolated provoked distal DVT without severe symptoms or risk factors for extension. Therefore, I have ensured that the patient has reliable followup for them to receive a repeat DVT doppler ultrasound in a week.

Cancer

  • Because patients with active cancer have variable responses to traditional VKA therapy, its use is contraindicated in this patient. I have counseled the patient that they should continue using low molecular weight heparin indefinitely or until they can receive updated recommendations from their PCP or oncologist.

Pregnant

  • Because vitamin K antagonist crosses the placenta and is potentially teratogenic, its use is contraindicated in this patient. I have counseled the patient that they should continue using low molecular weight heparin through the first 6 weeks of the postpartum period for a minimum period of 3 months or until they can receive updated recommendations from their OB-GYN.

[/accordion_item][accordion_item title=”Disposition”]DVT- Discharge

  • My clinical impression is that the patient has a presentation most consistent with a self-limiting and non-life threatening process. I have explained to the patient in appropriate terminology their diagnosis and provided anticipatory guidance for further management as an outpatient. I told them that we cannot definitively rule out a life-threatening cause of their symptoms during an emergency department visit, therefore they are absolutely required to follow-up with a physician to further assess them for risks of life-threatening causes of their presentation. If the patient cannot follow-up as an outpatient within a reasonable time period, that is, a few days, they should return to the ED so that we could help facilitate follow-up. I also explained to the patient that they were correct to present to the emergency department for this symptoms as I would prefer for them to err on the side of safety with this complaint and to continue to do so in the future. The patient has verbalized their understanding and at this time I feel they are stable for discharge home.
  • I have asked the patient to return to the ED should increased swelling, increased pain, fever, shortness of breath, fainting episodes, or worsening ability of range their lower extremities.

DVT+ Discharge

  • Because the patient has normal renal function, have a good social support system, have stated to me to have reliable followup, and is willing and able to self-inject LMWH or arrange for services to administer these medications and to conduct laboratory testing, it is strongly recommended by the ACCP that these type of patients undergo outpatient treatment. I have written the patient a prescription for 5 days’ worth of LMWH [and warfarin 10mg. I have counseled him on dietary constraints while taking VKA, provided strict instructions to follow up with his primary care provider for further monitoring and INR checks, and specified clear return precautions.] I have asked the patient to return to the ED should they experience increased swelling and/or pain, if they experience unexpected bleeding, including and not limited to the nares, mouth, skin, or anus.

DVT+ Admit

  • Because the patient [X], inpatient is admission is indicated for treatment of DVT.
    • home conditions and likelihood of reliable follow-up are inadequate
    • renal function is limited
    • have failed outpatient treatment
    • comorbidities

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