A Country Doctor Writes:

I was telling Autumn in the last few minutes of my “early dismissal” Friday before the Labor Day weekend that this was so much easier than in the earlier parts of my career.

Thursday I saw a man with a strange leg pain and swelling halfway down the lower leg as well as tenderness on the inside aspect of his thigh. The knee was a little swollen but moved just fine and the tenderness there was both above and below the joint.

He had already been to the ER and their workup included an X-ray but no labs.

I did some inflammatory markers that were mildly positive, a normal CPK, suggesting no muscle damage and a normal uric acid level, speaking against but not ruling out gout.

I had also ordered a D-dimer because there was tenderness over the femoral vein but no pain with testing the nearby adductor muscles against resistance. My strongest clinical impression was that this was an inflammatory process, so I prescribed prednisone.

2 pm Friday, going through labs before the big weekend, there was the D-dimer result: Mildly elevated.

The X-ray department had no openings for an ultrasound.

In the old days the choice would have been do nothing or send him to the emergency room where they would either commandeer an emergency ultrasound before releasing him or admit him for a heparin drip until a clot could be ruled in or out. Then, if he had a DVT, he would have been on heparin until his warfarin became therapeutic.

Today, I just called him up and explained about the test not being able to rule out a clot but could be a false alarm, for example due to inflammation. He had less pain, but no decrease in swelling.

I explained today’s choices, doing nothing until we could get an ultrasound or playing it safer and take samples of apixiban over the weekend as if he did have a clot and staying on it until we could get an ultrasound.

He chose the latter. I bagged up some samples and left them at the front desk. I walked out the back door almost on time, thinking again how much easier some things have become since I started out.

UPDATE, DAY AFTER LABOR DAY: THROMBUS IN PROXIMAL GREATER SAPHENOUS. “KEEP TAKING THE ELIQUIS THE WAY WE TALKED ABOUT AND SEE ME NEXT WEEK FOR A FOLLOWUP.”