55 Yo Woman Here With Concern Of Possible Clot In Her Leg
Patient present to the urgent care with right leg swelling and pain that is radiating into the right groin. Started yesterday and denies any trauma. Noticed the pain first and then started noticing swelling of the lower leg up to the mid shin. Hx of a DVT in the left leg 3x in the past. Most recent DVT diagnosed in 2005 and treated with warfarin. PMHx includes obesity, DM2 (A1c 6.3), HTN.
Denies any change in medication regimen.
Denies new supplements.
Denies recent long distance sedentary travel.
Vitals unremarkable. Temp 98.7.
Calf circumference 20″ on the right and 22″ on the left.
Tenderness over the erythematous portion of the lower right leg.
Distal pulses intact.
The erythema is slightly indurated and blanches rapidly.
There is tenderness along the medial upper thigh into the groin with no appreciable lymphadenopathy.
INR level 2.6
Note that the skin is indurated, generally this isn’t found with patients that just have a local reaction from PVD or sudden edema. There will be erythema with those patients but no induration and the calor is much less pronounced. Also, there is no reason for her to have tender lymphatic tract and inguinal groin tenderness unless some subclinical lymphangitis is present. She hasn’t mounted a fever but I don’t use that for clinical decision making. I could have been more conservative and allowed her to elevate the leg and perhaps use compression stockings but I didn’t find this patient to be compliant nor reliable enough to be able to judge when the cellulitis is worsening requiring her to need to start the antibiotics right away.
Confirmed: No, clinical diagnosis made.
Treatment/Outcome: Improved by day 3 on cephalexin 500mg TID for 10 days.