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Suspected proximal deep-vein thrombosis — MSRA MCQ

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Hardall topics relevant for this examSuspected proximal deep-vein thrombosisMSRA

A 67-year-old woman presents to her GP with a 2-day history of progressive left-leg swelling and aching. She is receiving chemotherapy for pancreatic cancer. Examination shows tenderness along the deep venous system, swelling of the entire left leg, calf circumference 4 cm greater than the right, and pitting oedema confined to the left leg. There is no cellulitis, Baker’s cyst, trauma or other alternative diagnosis judged at least as likely as deep-vein thrombosis (DVT). She has no chest pain, breathlessness, haemoptysis or syncope. She has no active bleeding, recent intracranial haemorrhage or other contraindication to anticoagulation. Blood has been taken for full blood count, renal and liver function, PT and APTT, but results will not be available until tomorrow. A quantitative D-dimer sample can be obtained immediately and reported within 2 hours. The local vascular service cannot provide a proximal leg vein ultrasound result for 8 hours. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Obtain a D-dimer sample, start interim therapeutic anticoagulation without waiting for baseline blood results, and arrange proximal leg vein ultrasound within 24 hours

This patient has a likely DVT by the 2-level Wells score: active cancer, localised deep venous tenderness, entire-leg swelling, calf swelling of at least 3 cm, and unilateral pitting oedema give a score well above 2. For likely DVT, NICE recommends proximal leg vein ultrasound with a result within 4 hours where possible. As this cannot be obtained within 4 hours, a D-dimer test should be taken first, followed by interim therapeutic anticoagulation and ultrasound with a result available within 24 hours. The sequence is important: anticoagulation may affect the D-dimer result, so option E is incorrect despite appropriately addressing the diagnostic delay. Option D wrongly withholds interim treatment while awaiting the D-dimer result; anticoagulation should follow sampling rather than await the result. Option C is unnecessarily indirect in a stable patient without features of pulmonary embolism or haemodynamic compromise, and it omits indicated interim treatment. Option B creates an unsafe diagnostic delay. Baseline FBC, renal and hepatic function, PT and APTT should be obtained, but NICE states that anticoagulation should not be delayed while awaiting their results.

Reference: NICE NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing — Recommendations (2012; amended 2020, with subsequent guideline updates) — https://www.nice.org.uk/guidance/ng158/chapter/recommendations