A 52-year-old man presents to the emergency department because of pain and swelling in his left leg over the past few hours. He traveled from Sydney to Los Angeles 2 days ago. He has had type 2 diabetes mellitus for 10 years and takes metformin for it. He has smoked a pack of cigarettes daily for 25 years. His temperature is 36.9°C (98.4°F), the blood pressure is 140/90 mm Hg, and the pulse is 90/min. On examination, the left calf is 5 cm greater in circumference than the right. The left leg appears more erythematous than the right with dilated superficial veins. Venous duplex ultrasound shows non-compressibility. Which of the following best represents the mechanism of this patient’s illness?
AImpaired venous blood flow
BSubcutaneous soft-tissue infection that may extend to the deep fascia
CInfection of the dermis and subcutaneous tissues
DImpaired arterial blood flow
EImpaired lymphatic flow
A 50-year-old man presents to the emergency department with pain and swelling of his right leg for the past 2 days. Three days ago he collapsed on his leg after tripping on a rug. It was a hard fall and left him with bruising of his leg. Since then the pain and swelling of his leg have been gradually increasing. Past medical history is noncontributory. He lives a rather sedentary life and smokes two packs of cigarettes per day. The vital signs include heart rate 98/min, respiratory rate 15/min, temperature 37.8°C (100.1°F), and blood pressure 100/60 mm Hg. On physical examination, his right leg is visibly swollen up to the mid-calf with pitting edema and moderate erythema. Peripheral pulses in the right leg are weak and the leg is tender. Manipulation of the right leg is negative for Homan’s sign. What is the next best step in the management of this patient?
ASend the patient to surgery for an emergency fasciotomy
BStart intravenous heparin therapy immediately
CMake a diagnosis of deep vein thrombosis based on history and physical
DPerform a venous ultrasound
EPerform intravenous venography within 24 hours
A 52-year-old woman comes to the physician because of swelling of her legs for 2 months. She has noticed that her legs gradually swell up throughout the day. Two years ago, she underwent a coronary angioplasty. She has hypertension and coronary artery disease. She works as a waitress at a local diner. Her father died of liver cancer at the age of 61 years. She has smoked one pack of cigarettes daily for 31 years. She drinks one to two glasses of wine daily and occasionally more on weekends. Current medications include aspirin, metoprolol, and rosuvastatin. Vital signs are within normal limits. Examination shows 2+ pitting edema in the lower extremities. There are several dilated, tortuous veins over both calves. Multiple excoriation marks are noted over both ankles. Peripheral pulses are palpated bilaterally. The lungs are clear to auscultation. Cardiac examination shows no murmurs, gallops, or rubs. The abdomen is soft and nontender; there is no organomegaly. Which of the following is the most appropriate next step in management?
ASclerotherapy
BCT scan of abdomen and pelvis
CCompression stockings
DAbdominal ultrasound
EAdjust antihypertensive medication
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