A 44 year-old obese female reports pain in the right lower leg and thigh for the last few days. She reports a dull pain on the medial side of her right thigh (figure 1) and along the lateral surface of her right knee joint (figure 2). She has a history of varicose veins in both lower extremities. Her temperature is 99 °F (37.2 °C), heart rate is 78 beats/min, blood pressure is 140/92 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 97% on room air. On examination, she is an obese woman. Physical examination is significant for induration, redness, and tenderness along the course of the local veins. The veins are erythematous, close to the surface, and palpable. There is erythema of the surrounding skin. Duplex ultrasound of the involved extremity reveals no deep venous thrombosis (figure 3). Figure 1 Which of the following is a true statement regarding this disorder?

A 58-year-old man comes to the emergency department complaining of severe pain in the right leg. He returned from Hawaii last night. The pain started mid flight without any notice. The patient has a history of IgA nephropathy and chronic kidney disease. His vital signs are given below: Height 6 ‘2; weight 342 lb; temperature is 98.4 ⁰ F, heart rate is 62 beats per minute, respiratory rate is 17 breaths per minute, and blood pressure is 145/88 mm Hg. Physical examination is significant for some tenderness over the right lower leg. Laboratory tests reveal the following: Test Result Reference range Erythrocyte count (RBC) 4.9 million/mm³ Male: 4.3 – 5.9 million/mm³ Female: 3.5 – 5.5 million/mm³ Erythrocyte sedimentation rate (Westergren) Male: 8 mm/h Male: 0-15 mm/h Female:0-20 mm/h Hematocrit 47% Male:41% – 53% Female: 36% – 46% Hemoglobin, blood 13.7 g/dL Male:13.5-17.5 g/dL Female 12.0 – 16.0 g/dL Creatinine 4.8 mg/dL 0.6 – 1.2 mg/dL Urea nitrogen 44 mg/dL 7-18 mg/dL Creatinine clearance 27 ml/min Male: 97 – 137 mL/min Female: 88 – 128 mL/min Sodium (Na⁺) 140 mEq/L 136 – 146 mEq/L Potassium (K⁺) 3.8 mEq/L 3.5 – 5.0 mEq/L Chloride (Cl⁻) 99 mEq/L 95 – 105 mEq/L Bicarbonate (HCO₃⁻) 26 mEq/L 22 – 28 mEq/L A duplex ultrasound of the right lower extremity shows a deep venous thrombosis. What is the most appropriate next step in the management of this patient?

You are treating a 44-year-old woman admitted to the hospital for deep vein thrombosis (DVT). As she is being discharged, you recommend treatment with warfarin. However, the patient refuses, citing concerns about frequent blood tests required for monitoring warfarin therapy. She mentions seeing a television commercial about a newer medication that does not require frequent blood monitoring. Using her phone, she finds information about a drug that works by directly inhibiting factor Xa. Which of the following medications fits her description and is appropriate for treating DVT?

A 44-year-old Indian woman presents to the emergency room with complaints of right leg soreness and fatigue. The pain began two days ago following a long flight from South Africa. Her medical history includes diabetes, and she is recovering from a hysterectomy performed 10 days ago. She interrupted her post-surgical recovery for a family emergency. She smokes one pack of cigarettes daily. Physical Examination: Obese, afebrile, and anxious. Right lower leg swelling with a calf circumference 4 cm larger than the left leg. Collateral superficial veins present. Entire leg swollen with pitting edema. Tenderness increases with calf compression and dorsiflexion of the right foot with the knee extended (positive Homan’s sign). No redness of the leg. A lower extremity ultrasound confirmed the diagnosis of deep vein thrombosis (DVT). What is the most appropriate anticoagulation therapy for the management of deep vein thrombosis in this patient?

A 44-year-old Indian woman presents to the emergency room with complaints of right leg soreness and fatigue. The pain began two days ago after a long flight from South Africa. Her medical history includes diabetes, and she is recovering from a hysterectomy performed 10 days ago. Due to a family emergency, she interrupted her post-surgery rest to travel. She smokes one pack of cigarettes daily. Physical Examination: Obese, afebrile, and anxious. Obvious swelling in the right lower leg, with a calf circumference 4 cm larger than the left leg. Collateral superficial veins are present. Entire leg swollen with pitting edema. Tenderness of the calf increases with gentle squeezing. Pain worsens with dorsiflexion of the right foot with the knee extended (positive Homan’s sign). No redness of the leg. The patient was admitted, and a lower extremity ultrasound confirmed the diagnosis of deep vein thrombosis (DVT). Which of the following does NOT increase the likelihood of deep venous thrombosis in this patient?

A 44-year-old Indian woman presents to the emergency room with complaints of right leg soreness and fatigue. The pain began after a long flight from South Africa two days ago. Her medical history includes diabetes, and she underwent a hysterectomy 10 days ago. She interrupted her post-surgery recovery to travel for a family emergency. She smokes one pack of cigarettes daily. Physical Examination: Obese and anxious. Afebrile. Right lower leg swelling with a calf circumference 4 cm larger than the left leg. Collateral superficial veins present. Entire leg swollen with pitting edema. Calf tenderness increases with gentle squeezing. Pain worsens with dorsiflexion of the right foot with the knee extended (Positive Homan’s sign). No redness of the leg. The patient was admitted to the hospital, and a lower extremity ultrasound confirmed the diagnosis. Which structure is most likely affected in this patient?

A 44-year-old Indian woman comes to the emergency room with complaints of soreness of the right leg and fatigue. The pain started after a long flight from South Africa two days ago. Her medical history is significant for diabetes. She has been recovering from surgical removal of her uterus (hysterectomy) performed 10 days ago. She had to fly due to a family emergency, interrupting her post-surgery home rest. She smokes one pack of cigarettes daily. On examination, she is obese, afebrile and anxious. She has obvious swelling in the right lower leg with calf swelling of 4 cm compared to the other leg. There are collateral superficial veins present; her entire leg is swollen with pitting edema. There is some tenderness of the calf that increases when the calf is gently squeezed. Her pain also increases with dorsiflexion of her right foot with knee extended. There is no redness of the leg. She was admitted to the hospital and later an ultrasound of her leg confirms the diagnosis. What is the most likely diagnosis in this patient?