A swollen leg and new breathlessness

Returned from Lagos nine days ago after a flight of just under seven hours. Six days ago the left calf began aching; four days ago the whole leg looked swollen. Over two days she has developed new exertional breathlessness and intermittent left-sided pain on deep inspiration. Comfortable at rest, with mild discomfort now.

No haemoptysis, syncope, resting breathlessness, orthopnoea, central crushing pain or radiation. No fever or rigors. These negatives help assess severity and alternatives; they do not exclude pulmonary embolism. A stable patient can deteriorate, so reassess observations during the encounter.

No previous VTE, recent operation, cast, major trauma, bed confinement or known cancer. No unexplained weight loss, breast lump, bowel change or urinary bleeding. Her mother had a PE after hip replacement at 60, required intensive care and recovered. There is no known familial thrombophilia.

No active bleeding, known ulcer, previous abnormal surgical bleeding, regular NSAID use or recent stroke. Ask about renal/liver disease, interacting medicines and previous heparin reactions before prescribing. Normal coagulation tests would not substitute for this history. Menopause was four years ago, with no subsequent vaginal bleeding.

Hypothyroidism treated with levothyroxine 100 micrograms daily. Oral continuous combined HRT: estradiol 1 mg/norethisterone acetate 0.5 mg daily, started 18 months ago. Colecalciferol 1,000 units daily; occasional paracetamol. No anticoagulants, antiplatelets or herbal remedies. No known allergies or kidney/liver disease.

HRT relieved severe flushes, insomnia and poor concentration. She does not initially regard it as relevant: a complete medicines history should uncover it. Never-smoker, modest alcohol intake, stable weight. Previous laparoscopic cholecystectomy was uncomplicated.

Deputy head teacher, independent, living with husband Emmanuel and two teenage children. She is frightened of repeating her mother’s intensive-care admission, worries that anticoagulation will be lifelong, and asks for a ‘clotting gene test’ for herself and her sister.

‘Please don’t stop my HRT. I couldn’t sleep or manage my job before it.’ She is due to fly to Dublin for a family wedding in three weeks. Roleplayer: ask for reasons and a practical alternative when HRT is discussed. Do not accept an unsupported guarantee that travel will be safe.

Pulse 96/min, BP 124/76 mmHg, respiratory rate 20/min, oxygen saturation 95% on air, temperature 37.1°C. Alert, warm peripheries, capillary refill under two seconds. Weight 78 kg; height 1.66 m. NEWS2 is 2 on standard oxygen scale 1: one point each for pulse and saturation. This is not a PE-specific risk classification.

With consent and appropriate exposure, compare both legs, inspect skin and measure calves at the same point, 10 cm below the tibial tuberosity. Left circumference 38.5 cm, right 34 cm: difference 4.5 cm. The entire left leg is swollen, with pitting confined to that leg up to mid-thigh, tenderness along the deep venous distribution and prominent non-varicose collateral veins. Distal pulses, colour, power and sensation are preserved.

There is mild warmth and erythema without an obvious skin break. No palpable superficial cord or obvious popliteal cyst. Do not use Homans’ sign or forceful calf squeezing. Neither examination nor the appearance of the skin reliably separates DVT from cellulitis; they can coexist.

Speaking in full sentences. Clear lungs, normal heart sounds, no raised JVP or clinical right-ventricular heave. Abdomen soft without palpable mass. These findings do not exclude PE, right-heart strain or an occult cause of thrombosis.

Look for alternative explanations and complications rather than performing a ritual cancer examination. Additional intimate examination requires a clinical indication, consent and appropriate chaperoning; it is not an automatic requirement for every patient with VTE.

DVT Wells score is 5: entire-leg swelling, calf difference at least 3 cm, unilateral pitting, deep venous tenderness and collateral superficial veins each score one. No alternative is judged at least as likely in this scenario. DVT is therefore likely. PE Wells score is 6: clinical DVT signs score three and PE being more likely than alternatives scores three. Pulse 96 does not earn tachycardia points; neither HRT nor the flight adds a Wells point.

Request ECG and chest radiograph to assess alternatives; supplied later they are unremarkable. FBC: Hb 132 g/L, WBC 8.4, platelets 254 × 10⁹/L. Sodium 139, potassium 4.1 mmol/L, creatinine 68 micromol/L; liver profile normal; PT 12.1 seconds and APTT 30 seconds. These support safe prescribing but do not exclude every contraindication. Calculate creatinine clearance using the appropriate local method rather than copying an unexplained estimate from a draft.

If a D-dimer is requested, it is 2,100 micrograms/L FEU. It does not confirm a clot. With likely PE, a D-dimer should not be used as a gatekeeper to delay definitive imaging.

CTPA: emboli in segmental and subsegmental left lower-lobe pulmonary arteries; RV:LV ratio 0.8, without reported RV dilatation. Proximal ultrasound: non-compressible thrombus in the left common femoral, femoral and popliteal veins. ‘Femoral vein’ is a deep vein despite the misleading older term ‘superficial femoral vein’.

Now the diagnosis is confirmed proximal DVT with PE. Before this card, it remains suspected. Normal troponin and absence of RV dilatation contribute to risk assessment after imaging; normal ECG or troponin alone would not establish absence of right-heart strain.

The leading concern is DVT with associated PE. The leg findings and new pleuritic pain/breathlessness fit one unifying diagnosis. Muscle strain or a ruptured Baker cyst could explain leg pain but do not readily explain the complete picture. Cellulitis remains possible, particularly if infection features emerge. Pneumonia, pneumothorax and cardiac causes require consideration according to findings; no single normal test eliminates every alternative.

Oral HRT and travel are relevant risks. Do not claim which contributed more to this individual event. Her mother’s postoperative PE does not prove an inherited disorder. Establishing risk factors helps later decisions but must not delay acute assessment.

For likely PE, arrange CTPA immediately if possible. Discuss a V/Q alternative where contrast allergy, severe renal impairment or irradiation concerns make it appropriate. NICE permits clinical judgement about which pathway to investigate first when both DVT and PE are suspected; breathlessness and chest symptoms make PE assessment a priority here.

If imaging cannot be performed immediately, offer interim therapeutic anticoagulation after clinical assessment for contraindications. Send baseline FBC, renal/liver function, PT and APTT without waiting for results when treatment is indicated; review results within 24 hours. Choose the agent under local guidance, preferably one suitable for continuation if confirmed. This does not mandate apixaban or exclude LMWH.

An isolated-DVT rule for stopping interim treatment after negative leg ultrasound must not be applied while likely PE remains unresolved. A negative CTPA also does not finish the investigation of a persistently suspicious swollen leg. Track both clinical questions to an explicit conclusion.

For confirmed proximal DVT/PE, discuss anticoagulation for at least three months. In a suitable adult, apixaban or rivaroxaban are NICE options. If apixaban is selected, the adult acute-VTE regimen is 10 mg twice daily for seven days, then 5 mg twice daily. Check renal function, interactions, bleeding risks and product information; do not import atrial-fibrillation dose-reduction rules into acute VTE treatment.

Explain that anticoagulants reduce clot extension and further emboli while the body resolves clot; they are not an instant mechanical removal. Discuss adherence, an anticoagulant alert card, medicine interactions and urgent help for major bleeding or head injury. Arrange a named thrombosis-team contact and review.

Do not discharge solely because she looks comfortable or NEWS2 is low. A validated PE risk assessment, bleeding/comorbidity review, access to medicines, support and reliable follow-up are required for outpatient suitability. If these are not secured, continue hospital assessment. Thrombolysis is not routine for a haemodynamically stable patient.

Before results: ‘A clot in the leg, possibly with a clot in the lung, is my main concern. We need scans to establish that. Your observations are stable at present, but that does not make it safe to ignore. If a scan is delayed, I recommend treatment to reduce further clotting after checking the bleeding risks.’

After confirmation: ‘The scans have confirmed a leg clot and clots in the lung. I understand why your mother’s experience is frightening. Her course does not predict yours. We will use your observations, scan and other assessments to decide the safest setting for treatment. I cannot promise that there is no risk, but we now have a treatment and follow-up plan.’ Do not call a suspected clot ‘small’ before imaging or equate anatomical size with a guaranteed benign course.

Acknowledge the benefit she experienced from HRT. With confirmed VTE, discontinue this oral estradiol/norethisterone product; its prescribing information identifies VTE as a contraindication. Explain the reason, and arrange menopause-specialist input for symptom management. Do not promise that changing immediately to a patch is risk-free or appropriate without individual review.

‘Stopping the tablets does not mean abandoning your symptoms. Let us arrange help with sleep and flushes and discuss safer options with the menopause team. At the anticoagulation review we will weigh the provoking factors, recovery, ongoing risks, bleeding and your preferences. It is too early to promise either lifelong treatment or an automatic stop on a fixed date.’

Routine thrombophilia testing is not indicated for a provoked event simply because her mother also had a provoked PE. Explain whether a result would change management, and seek specialist advice if a different personal/family history emerges. Do not promise fitness to fly in three weeks before completing assessment; arrange individual advice and discuss postponement if needed.

Ask her to explain the diagnosis, treatment schedule and who she would contact. Worsening breathlessness, collapse, severe chest pain or major bleeding require emergency help. Give written medicine instructions and direct/out-of-hours contact details rather than only ‘see your GP’.

Confirm prescriptions, first doses, investigation results, follow-up ownership and a three-month treatment review. New cancer symptoms require appropriate investigation regardless of whether the event has a provoking factor; a blanket scan for occult cancer is not a substitute for clinical assessment.

Stop the routine consultation, use an emergency ABCDE approach and call senior/critical-care help. Suspected high-risk PE requires urgent diagnosis and resuscitation planning. For confirmed haemodynamically unstable PE, NICE recommends continuous UFH and consideration of thrombolysis, with bleeding risk assessed. An outpatient DOAC prescription is no longer the appropriate pathway.

Urgently assess and manage the bleeding with senior support. Do not give an unexamined routine anticoagulant dose. Balance both life-threatening risks with the thrombosis/acute team. An IVC filter may be considered when anticoagulation is contraindicated; it is not routine and requires a documented removal strategy when anticoagulation becomes possible.

Reconsider contrast imaging and calculate creatinine clearance for prescribing. Discuss V/Q imaging and an appropriate anticoagulant strategy with radiology, pharmacy and the treating team. Do not apply the standard example dose indiscriminately or assume that the laboratory eGFR resolves every drug-dosing question.

Arrange examination with consent/chaperoning and the appropriate urgent breast pathway. Do not dismiss it because HRT offers a provoking factor. If cancer is confirmed, reconsider anticoagulant selection, interactions, bleeding and duration with oncology/thrombosis specialists. Continue treatment of the acute clot while coordinating the additional investigation.

Strong: Elicits HRT and bleeding risks, quantifies the leg findings and explores her mother’s history.

Incomplete: Records ‘swollen calf’ without measurement or medicines.

Unsafe: Assumes muscle strain explains new breathlessness or uses normal observations to exclude PE.

Strong: Calculates and explains both Wells scores, stages results and closes both diagnostic pathways.

Incomplete: Names scores without showing their components.

Unsafe: Stops the PE pathway because a leg scan is negative or labels an unscanned patient confirmed low risk.

Strong: Selects safe interim/confirmed therapy, checks contraindications and ensures follow-up.

Incomplete: Says ‘start a blood thinner’ without a prescribing or monitoring plan.

Unsafe: Improvises a low acute-VTE dose or discharges without risk assessment.

Strong: Addresses fear, HRT benefit and testing expectations without false promises.

Incomplete: Lists side effects but does not check understanding or access to treatment.

Unsafe: Guarantees fitness to fly or tells her treatment will definitely stop at three months.

Calculate DVT and PE probability separately; neither HRT nor air travel adds a Wells point. A likely PE pathway goes directly to imaging, with interim therapeutic anticoagulation if imaging is delayed and no contraindication is identified.

Stable observations and a low NEWS2 do not establish outpatient suitability. Confirmed proximal DVT or PE requires at least three months of anticoagulation, followed by an individual review rather than an automatic stop or lifelong promise.

Hormonal therapy makes this a provoked event under NICE terminology. Routine thrombophilia testing is not indicated for a provoked VTE, and a relative's postoperative PE does not by itself prove inherited thrombophilia.

An IVC filter is not routine: NICE limits consideration to defined circumstances such as a contraindication to anticoagulation, with a documented removal strategy.

The strongest PACES answer closes the diagnostic pathway, gives a safe prescribing plan and addresses the patient's real priorities about HRT, family history and travel.

For a second rehearsal, calculate both Wells scores aloud before revealing any investigation card. Then explain the scan sequence, interim treatment, bleeding checks and the three-month review in under two minutes without promising an outcome that has not yet been established.