29th February 2024

A 68-year-old man presents to the emergency department with a 2 day history of pain and swelling in his right leg.

A 68-year-old man presents to the emergency department with a 2 day history of pain and swelling in his right leg. He denies haemoptysis, chest pain, or shortness of breath.

He is otherwise well and has recently returned from New Zealand, where he was visiting his daughter and son-in-law.

PMH. Hypertension, type II diabetes mellitus. DH. Amlodipine 5mg PO daily, metformin 500mg PO daily NKDA. SH. Former smoker.

The department is currently unable to arrange an ultrasound scan until tomorrow morning.

A D-dimer level is therefore requested, and the registrar asks for appropriate treatment to be given in the interim to cover the most likely diagnosis.

On examination

Unilateral enlargement of the right lower leg by >3cm compared to the left, with overlying erythema. Affected area tender to palpation.

Temperature 36.9, HR 92/min and rhythm regular, BP 143/78 mmHg, RR 16/min, O2 sat 98% on air

Weight 72kg

Investigations

WCC 10.8 (4.0 – 11.0 x 109/L)

CRP 55 (< 3 mg/dL)

D-dimer 5200 (< 500 ng/ml)

eGFR 78 (60<)

PT 11 (10 – 14 secs)

APTT 26 (25 – 35 secs)

Please select the most appropriate initial management option for this patient: