CASE 80: PAIN IN THE LEG
History
A 38-year-old woman presents to the emergency department with a painful left calf. She
had woken that morning to notice that her calf was swollen and found it painful to put her
foot to the ground. There was no history of recent air travel or long-distance car journeys.
She is otherwise well, is not breathless and has no chest pain. She has had no previous
medical illnesses other than some cartilage problems in the knees. In her obstetric history
she has had two first-trimester miscarriages and has not had any successful pregnancies.
There is no family history of note. The patient is married. She is a teacher of physical edu-
cation and exercises regularly. She neither smokes tobacco nor drinks alcohol. The oral
contraceptive is the only medication that she takes.
Examination
She is a little overweight. Her left leg is clearly swollen, with a 4 cm difference in circum-
ference around the left calf measured 10 cm below the tibial tuberosity. There is tenderness
on palpation of the calf. The left calf is slightly warmer than the right. There is a small effu-
sion in the right knee, which is not hot or painful. There is some pitting oedema in the left
ankle and there are superficial veins evident in the left leg. Physical examination is other-
wise normal.
NormalHaemoglobin 12.2 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 86 fL 80–99 fL
White cell count 7.4% 109 /L 3.5–11.0% 109 /L
Platelets 328 % 109 /L 150–440% 109 /L
Sodium 141 mmol/L 135–145 mmol/L
Potassium 4.6 mmol/L 3.5–5.0 mmol/L
Urea 4.9 mmol/L 2.5–6.7 mmol/L
Creatinine 111 &mol/L 70–120&mol/L
Glucose 4.8 mmol/L 4.0–6.0 mmol/LProthrombin time: normal
D-dimers: raised
Activated partial thromboplastin time: prolongedINVESTIGATIONS
Questions
- What is the cause of the swollen leg?
- How would you investigate and manage this patient?