A 57-year-old postmenopausal woman presented to our emergency department with a 1-day history of left leg pain, redness, and swelling. She reported no chest pain or shortness of breath. During the previous week, she made several car trips, each lasting 3 hours. Her medical history was remarkable for a left femoral and popliteal deep venous thrombosis (DVT) after breast reduction surgery during the previous year, which was treated with 1 week of subcutaneous low-molecular-weight heparin therapy and 6 months of oral warfarin therapy. She also had a history of hyperlipidemia, allergies, gastroesophageal reflux, and depression. She denied using tobacco or illicit drugs. Breast, cervical, and colon cancer screening were current and unremarkable. Daily oral medications were atorvastatin, sertraline, montelukast, and pantoprazole. She reported no family history of DVT.On arrival at the emergency department, the patient's vital signs were as follows: temperature, 36.8°C; blood pressure, 150/77 mm Hg; heart rate, 71 beats/min; respiratory rate, 18 breaths/min; and room air oxygen saturation, 93%. Physical examination revealed erythema, warmth, tenderness, and swelling of the entire left leg with intact distal pulses ( Figure 1). The right leg was unaffected. Laboratory tests revealed the following: white blood cell count, 9.3 × 10 9 /L; hemoglobin, 14.7 g/dL; platelets, 321 × 10 9 /L; creatinine, 0.7 mg/dL; activated partial thromboplastin time, 23 seconds; and international normalized ratio, 0.9.
Which one of the following is the most likely diagnosis in our patient? a. Deep venous thrombosis b. Muscle strain c. Superficial thrombophlebitis d. Ruptured Baker cyst e. CellulitisDeep venous thrombosis is the most likely diagnosis given the prior DVT, recent car trips, and clinical findings. One can assess the probability of DVT by using the Modified Wells Clinical Score.1 One point each is given for clinical features, such as active cancer, paralysis or recent lower extremity immobilization, being bedridden for more than 3 days within the previous 4 weeks, localized tenderness along the deep venous system, whole leg swelling, calf swelling by more than 3 cm compared with the asymptomatic leg, pitting edema, collateral superficial veins, and previous DVT. Two points are subtracted when an alternative diagnosis is more likely than DVT. A score of 2 or more indicates that DVT is likely, whereas a score of 1 or less indicates that DVT is unlikely. Our patient's score was 2, indicating that DVT was likely.Muscle strain can mimic DVT; 40% of patients with suspected DVT but negative findings on contrast venography have muscle injury as the cause of lower extremity symptoms.2 Our patient, however, had not experienced a recent injury. Superficial thrombophlebitis (ie, acute inflammation of a superficial vein caused by a thrombosis) usually presents with a palpable cord, inconsistent with our patient's clinical findings. A ruptured Baker (popliteal) cyst can mimic DVT because it causes leg pain and swelling. However, a ruptured Bake...