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Difficulty: EasyHematology and Oncology

A 45-year-old man presents to the outpatient clinic with a 2-day history of right calf pain and swelling. He recently returned from a 14-hour international flight. He has no chest pain, shortness of breath, or hemoptysis. His medical history is unremarkable, and he takes no medications.

Vital signs are:
Temperature: 37.0°C (98.6°F)
Heart rate: 78/min
Blood pressure: 125/80 mmHg
Respiratory rate: 14/min
Oxygen saturation: 98% on room air

Physical examination reveals a 4 cm increase in the circumference of the right calf compared to the left. The right calf is warm, tender to palpation, and exhibits mild erythema.

Laboratory panels reveal:
Hemoglobin: 14.8 g/dL
Mean corpuscular volume (MCV): 88 fL
Platelet count: 260,000/mm³
White blood cell count: 8,100/mm³
Serum creatinine: 0.9 mg/dL
Prothrombin time (PT): 12 seconds
Activated partial thromboplastin time (aPTT): 30 seconds

A comprehensive duplex ultrasonography of the right lower extremity demonstrates a non-compressible segment in the right popliteal vein.

Which of the following is the most appropriate next step in management?

  1. Initiate oral apixaban therapyAnswer
  2. B
    Order a serum D-dimer assay
  3. C
    Administer intravenous broad-spectrum antibiotics
  4. D
    Administer intravenous furosemide
  5. E
    Reassure the patient and advise lower extremity elevation

Answer

The most appropriate next step in management is to initiate oral apixaban therapy.
This patient has a confirmed, uncomplicated acute deep venous thrombosis (DVT) in the popliteal vein. He is hemodynamically stable, has normal renal function (creatinine 0.9 mg/dL), and has no active bleeding or high-risk comorbidities. The standard of care for an initial episode of proximal DVT is immediate therapeutic anticoagulation. Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban are currently preferred over warfarin because they have a rapid onset of action, do not require a parenteral bridging agent (like low-molecular-weight heparin), and do not require routine laboratory monitoring. Since the patient is completely stable with normal vital signs, he can be safely treated in the outpatient setting.

Step-by-Step Solution

1
Evaluate the clinical presentation and diagnostic findings.
The patient has signs, symptoms, and a confirmed ultrasound diagnosis of an acute right popliteal deep venous thrombosis (DVT).
To establish the correct diagnosis before initiating any targeted treatment.
2
Assess the patient's clinical stability and bleeding risk profile.
The patient is hemodynamically stable, has normal renal function, and normal baseline coagulation panels.
To determine the appropriate setting (inpatient vs. outpatient) and ensure there are no contraindications to anticoagulation.
3
Select the optimal therapeutic intervention.
Initiation of a direct oral anticoagulant (DOAC) such as apixaban.
DOACs are the standard of care for acute, uncomplicated DVT because they are highly effective, do not require laboratory monitoring, and can be administered orally in an outpatient setting.

Key Concept

Management of acute, uncomplicated deep venous thrombosis (DVT) with direct oral anticoagulants.
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Topics

Hematology and Oncology

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