From the Research
This patient likely has a condition that requires further evaluation for deep vein thrombosis (DVT) or other causes of unilateral leg swelling, despite the normal D-dimer level, given the symptoms of left lower extremity swelling, edema, and calf pain. The current Eliquis (apixaban) dose of 5 mg once daily is appropriate for atrial fibrillation prophylaxis, but the presence of leg swelling and calf pain warrants further investigation, as suggested by 1. A normal D-dimer level does not completely rule out DVT, especially in patients with a high clinical suspicion, as noted in 2. I recommend ordering a lower extremity ultrasound to evaluate for DVT, as well as considering other potential causes of leg swelling, such as May-Thurner syndrome, as described in 3, or a Baker's cyst, as mentioned in 4. The patient should be monitored for signs of pulmonary embolism, including shortness of breath, chest pain, or rapid heart rate, and emergency evaluation should be sought if these symptoms develop. Elevation of the affected leg above heart level when resting and regular walking when possible may help reduce swelling. Once the diagnosis is confirmed, consideration of hematology consultation may be necessary to evaluate for underlying causes beyond atrial fibrillation, especially if this is a first thrombotic event, as discussed in 5 and 2. Key points to consider in the diagnosis and management of this patient include:
- Clinical presentation of unilateral leg swelling, edema, and calf pain
- Normal D-dimer level, which does not completely rule out DVT
- Need for further evaluation with lower extremity ultrasound
- Consideration of other potential causes of leg swelling, such as May-Thurner syndrome or Baker's cyst
- Monitoring for signs of pulmonary embolism and emergency evaluation if symptoms develop.