Case 39 – the beginning

Welcome to case 39, a short case exploring DVT/PE management. Sound dull? Well, we’re going to show you why it’s not just a DVT.

This case is particularly aimed at:

  • General medics
  • Surgeons
  • Medical students
  • Nursing students
  • Acute medicine practitioners of all stripes.

So, here we go…

A 76 year old man is referred to the Acute Medical Unit/A&E by his GP. He presented with 3 days of progressive leg swelling and pain. His leg looks like this:


You are asked to see and assess him.

What will you do next?

Answers via Twitter please and always include #teamhaem in your answer. Please follow the case through the week as there is plenty more to come and lots to learn. All answers valued.

Please remember TeamHaem use fictitious cases to protect patient identity. We are not in a position of authority but rather aim to promote discussion and facilitate learning.


About TeamHaem

Online education and discussion about all things haematological
This entry was posted in Anticoagulation, Related to other specialities, Thrombosis and tagged , , , , . Bookmark the permalink.

2 Responses to Case 39 – the beginning

  1. olitodd1984 says:

    Is this cellulitis? Is there a history of fever, sweats rigors, loss of appetite? On exam is there warmth, tracking erythema up the lymphatics, proximal lymphadenopathy? Is there an entry point for a bug or bad times pedis with cracked skin?

    Worse is there subcutaneous crepitus suggestive of nec fasc? Is the groin involved?

    Going back to history is it all acute, did it come on gradually or suddenly? Are the signs of chronic venous insufficiency? Are there signs of chronic arterial disease? Are dp and pt pulses palpable and what is the cap refill?

    Is the patient diabetic, is sensation intact?

    In terms of DVT are there risk factors – malignancy, smoking, coagulopathies or immobility?
    In terms of Lymphatic Obstruction is there an obstructing mass in the abdomen, genitourinsry tract or rectum on that side?

  2. olitodd1984 says:

    Rule out infection- in the history ask about fevers, sweats, rigors, loss of appetite. On exam, look for rubor, callor, or dolor, erythema that tracks up the lymphatics, proximal lymphadenopathy, an entry point for bugs especially in the feet, particularly tinea pedis causing broken skin.

    Worse, is there subcutaneous crepitus in keeping with NEC fasc, is the groin involved as in Fourier’s? This would need urgent surgical review.

    Chronic venous or arterial insufficiency? Is there a hsitory of earlier disease – was the onset gradual or very acute? Are there signs of chronic venous disease – lipodermatosclerosis, venous ulcers, varicositities, previous surgery? Arterial disease – cap refill, are dp and pt pulses present?

    Could it be an arterial embolus? Pulses absent, pale cold distal limb?

    Is there lymphatic obstruction? I would examine the abdomen, groin, and prostate/ rectum for an obstructing mass. Ask in the systems review about weight loss, change in bowel habits, and GU bleeding.

    Are there risk factors for dvt- smoking,malignancy, immobility, coagulation disorder? Is the calf itself tender on compression? Are there clinical signs of PE- raised JVP? Right parasternal heave, tachypnoea?

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