32 yo F with unilateral leg pain and swelling

[Doczilla]

Another case. Bringin' the medicine...

32 yo obese but otherwise healthy female comes to the ED with a chief complaint of R leg pain and swelling for 1 day. She says that she noticed it was a little more swollen this morning, and gradually has worsened throughout the day. No fever, chills, chest pain, SOB, nausea, vomiting, diarrhea, dysuria, vaginal bleeding or discharge, or new rashes. No recent travel or immobility.

PMHx: Obesity
Meds: None
Allergies: NKDA
Social hx: Nonsmoker. Occasional social use of EtOH, denies drug use. Homemaker.
LMP: 1 week ago, normal time, normal flow, nothing remarkable

VS from triage: P 117 R 14 BP: 132/72 SaO2 99% on room air.
Exam: Alert, oriented, no apparent distress. Converses easily and pleasantly.
HEENT: Unremarkable. Oropharynx clear, no meningeal signs, no JVD.
Chest: Lung sounds clear and equal bilaterally. Heart sounds regular rate and rhythm, tachycardic, no murmurs, rubs, or gallops.
Abdomen soft, nontender, nondistended, with normal active bowel sounds.
GU/Pelvic: deferred.
Extremities: RUE, LUE, LLE unremarkable. Right leg noticeably swollen from mid-thigh to the foot, mildly tender to palpation. No obvious venous engorgement, no masses. 2/2 pulses. No erythema or warmth.

Differential diagnosis contains DVT, lymphedema, obstructing mass, cellulitis.

Concerning is her elevated heart rate, which I confirm by palpation at the bedside. Monitor shows a sinus tach at 110-115. Pulse ox remains 99% on room air. She again denies any chest pain, SOB, cough, or fatigue.

CBC is unremarkable. Normal WBC count with normal differential. Blood sugar normal. BMP normal.

At this particular facility, D-Dimer is not readily available (must be sent by courier to another hospital). I order ultrasound of her leg and CT scan of the chest with IV contrast (PE protocol). Ultrasound shows no DVT, but CT scan is positive for bilateral pulmonary emboli. We give the first dose of Lovenox 1mg/kg SQ, and admit her.

Important points from this case:
Vital signs are just that: vital. Her pulse was the only reason that we looked at her for PE. With a negative DVT screen, we otherwise would have sent her home for follow-up ultrasound as an outpatient.

Do not ignore abnormal vital signs. Be able to explain them clinically. If she was writhing in agony, then her elevated heart rate would not be unusual. In this comfortable-appearing patient, it doesn't fit.

DVT ultrasound is very good but not perfect. Likely the clot simply migrated to her lungs, leaving a radiographically insignificant amount of clot in the vein.

D-Dimer is helpful in patients with low pre-test probability of clot. She was moderate to high pre-test probability, so a D-dimer wouldn't add much to the diagnosis unless it, and the ultrasound and CT, were all negative.

'zilla

[Semper gumby]

Just a question about D-dimer, if the patient did have cellulitis, wouldn't that raise the D-dimer also? I know it's raised in rhuematoid disease, and some others...

A lot of the ER's I have worked next to don't put that much into D-dimer anyways. It's a good diagnostic tool, but has it's flaws. They order venous duplex of the legs/arms based off of clinical appearance. I'm sure some are just doing the CYA thing, not to say I don't blame them. (Good pick up with the tachycardia....)

Respectfully,

Mike

[Red Flag 1]

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[Patriot007]

Doczilla,

Thank you for taking the time to post these cases each with an important lesson. Looking forward to learning more from you.

[swatsurgeon]

just to extend this one alittle....troop transport, in a seat for several hours, dehydrated, anxious/stressed (circulating hormone levels not baseline). Same presentation, yet young healthy soldier....possible PE?
What do you think?

ss

[Patriot007]

Just a trainee but I'll take a stab.

Possible, yes if there is anything I've learned never say never.

Probable, I don't think so. It would be very low on my differential.

Major risk factors for PEs mainly consist of factors that would keep a soldier from duty- relatively recent surgery, chronic heart disease, deficiency of clotting inhibitors, ect...

I know there is evidence linking increased hormone levels to PEs but in a healthy young soldier I don't think it greatly increases the likelihood.