Case scenario: 

A.A. is a 28 y/o female with no past medical history who presents complaining of left leg pain for two days. 

Responses to appropriate history questions: 

• Onset: 2 days ago 
• Location: behind the left calf 
• Characteristics:  achy, dull constant pain
• Came on gradually, worsening since it began  
• No radiation
• Were you doing anything when the pain started: Just taking care of my two week old daughter 
• Alleviating/Aggravating factors: Tried 600mg Ibuprofen with no relief. Nothing makes it better. Feels worse when walking. 
• Severity → 5/10 
• Any recent trauma such as MVA, fall, hit leg: denies 
• Recent long travel: denies 
• Recent surgery: denies 
• Medical history. Normal spontaneous vaginal delivery two weeks ago with no complications 
• Are you on any medications: denies taking medication 
• No fever
• No chills
• No chest pain
• No palpitations
• No shortness of breath
• No headache
• No blurry vision
• No abdominal pain
• No joint pain
• No warmth of left lower extremity
• She has noticed some left lower extremity swelling 

Past medical history: denies 

Past surgical history: tonsillectomy 18 years ago

Medications: denies 

Allergies: No known drug, environmental or food allergies  

Family history: Denies any cardiovascular, pulmonary or blood clotting disorders in the family. 

Social history: Lives with husband and two-week-old daughter. Denies alcohol, tobacco, or illicit drug use. 

Physical Exam: 

• Vital signs:
  • T 98.1 F
  • HR 80 bpm
  • RR 14 breaths/min unlabored
  • BP 110/82
  • O2 sat 98% on room air
  • Height: 5’5”
  • Weight: 145lb
  • BMI: 24.13
• General: alert and oriented to person/place/time, in no acute distress, sitting upright in chair. Well-nourished, dressed appropriately.
• Skin: Warm and moist. No rashes or lesions.
• HEENT: normocephalic, atraumatic. Sclera non-icteric. EOM intact.
• Heart: regular rate and rhythm, S1, S2 noted with no murmurs.
• Lungs: Clear to auscultation bilaterally, breath sounds equal bilaterally. No use of accessory muscles.  
• Abdomen: soft, nontender, nondistended.
• Lower extremities: left lower extremity mildly edematous with slight discoloration and pain to palpation of calf. Right lower extremity with no swelling, pain or discolorations. +Homans sign to the left lower extremity. DP/PT pulses 2+ bilaterally. No lesions or rashes bilaterally. Full range of motion of bilateral lower extremities. 5/5 strength and sensation intact bilaterally.

Differential Diagnoses: 

• Deep vein thrombosis: Left lower extremity pain with edema and mild discoloration. Positive Homan sign, although this sign is not very sensitive or specific. Recent birth making the patient hypercoagulable.
• Muscle strain: Pain worse with walking, pain to calf muscles, unilateral.
• Venous insufficiency: Recently pregnant causing increased venous pressure and blood volume. However, the patient had no varicosities on physical exam and diffuse swelling and discoloration is less likely in venous insufficiency. 
• Rhabdomyolysis: Less likely, no history of crush injury or excessive exercise. Patient has swelling, tenderness and discoloration to the left lower extremity. 

Tests: 

• CBC: all within normal limits
• CMP: all within normal limits
• CK: within normal limits 
• D-dimer: could be ordered, however it may still be elevated regardless due to the patient being only two weeks postpartum.
• PT/PTT/INR: 11 seconds, 30 seconds and 1 respectively (within normal limits)
• EKG: NSR at 75 bpm with no ST elevations or depressions.
• US LLE venous duplex: non-compressible left popliteal vein with increase venous diameter and lack of flow with calf squeeze [image included below]  popliteal DVT is the diagnosis

Treatment: 

• Initial anticoagulation: Low molecular weight heparin Enoxaparin [Lovenox] subcutaneously 1mg/kg every 12 hours up to ten days. Initiate warfarin within 72 hours of starting Lovenox and continue for at least five days and until INR is between 2 and 3.
• Other initial treatment options include subcutaneous fondaparinux, oral factor Xa inhibitors or unfractionated heparin.
• Patient is hemodynamically stable, and discussion can be had about inpatient versus outpatient therapy.
• Additional conversation of long-term anticoagulation [three months] will also be needed. 

Patient counseling: 

• Discuss the importance of early ambulation.
• Advise patient there is no contraindication for breastfeeding with Enoxaparin (Lovenox) or Warfarin, therefore the patient can continue breastfeeding if she chooses.
• Patient must follow up and be monitored closely while on anticoagulation. 
• Educated the patient on DVTs and the side effects of anticoagulation. Discussed that the anticoagulant does not dissolve the DVT she currently has but will limit further thrombus formation and allow for fibrinolysis.
• Discuss signs and symptoms of deep vein thrombosis and pulmonary embolism.  

Sources: 

• https://wikem.org/wiki/DVT_ultrasound
• UpToDate: Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity
• https://med.emory.edu/departments/emergency-medicine/sections/ultrasound/image-of-the-fortnight/soft-tissue-vascular-msk/massive_dvt.html
• UpToDate: Overview of the treatment of lower extremity deep vein thrombosis (DVT)
• Pulmonary Thromboembolism and Deep-Vein Thrombosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Manual of Medicine, 20e. McGraw-Hill