mm hmm. Well thank you so much. Dr cho Uh and thank you everyone for inviting me to speak. Um so I thought that since this is a consult, we present a case. Um so this is a patient I saw just a couple of weeks ago, 65 year old guy with left leg swelling over a couple of weeks. Um he's a patient who's known to me. He'd been wearing a brace for left knee arthritis and his brace was kind of tight and he had developed left calf and ankle swelling and he said, you know it's it's even there first thing in the morning compression sex aren't helping. He has a history of a soglio DVt. So an isolated distal DVt that was diagnosed about a decade ago and monitored with serial ultrasound. And then more recently he had a proximal DVt in the same limb. And he was treated with anti coagulation for about six months. And then he after discussion of risks and benefits decided he wanted to stop so he could donate plasma. So we put him on aspirin. And when I examined him he had pretty impressive pitting edema below the knee. His leg was inaugurated, it was warm, his calf was tender, tender and he had some mild venus act asia. So I thought, oh darn uh this was a mistake stopping his anti coagulation. So when we're thinking about DVT we really want to think about pretest probability. So before we jump to our next test, we want to understand what's the likelihood that this person has a DVT and unfortunately the signs of DVT are really non specific. So there are a lot of mimics just as with superficial thrombosis, phlebitis, cellulitis, muscle injuries, a ruptured baker cyst, a flare of the post probiotics syndrome, and then superficial thrombosis phlebitis. And unfortunately also our physical exam is non specific. So there are a few things that can help us. So in particular differences in calf diameter or absence of swelling or absence of difference um in calf diameter can help us rule in or rule out, but we're never really going to make the diagnosis on physical exam. So the well's criteria, probably the best known um um risk assessment model for trying to figure out whether my patient has DVT. And so um you know, I'm a fairly experienced provider, I have my own clinical gestalt, but when I actually went through and calculated this in retrospect, he's got a pretty high pretest probability. So obviously the next step was whole leg ultrasound. Now, if you do not have access to holy ultrasound for a person who is high pretest probability, then we would really recommend. And the guidelines would recommend empirical therapy. So there are no data addressing this, it's really based on expert consensus um and no data addressing what's the timeframe in which we should start anti coagulation. Um typically I do about 24 hours. So the goal here is to minimize the robotic risk while avoiding the risks that are associated with anti coagulation. So bleeding is the most important but also cost inconvenience to the patient. And then I'm not going to go through this. But here's a nice algorithm for how to use your pretest probability in conjunction with the timer. So I proceeded to imaging so you can see in the left panel this patient has a dilated gastric vein. I don't have the same loop here, but it's non compressible but interestingly, he also had uh in the pop latino Fassa, this um complex non vascular cystic structure that was radiated or or tracked into his calf, presumably a ruptured baker cyst or a torn muscle. So the next steps for this patient because of the gas truck dvt and his prior history. I did have him resume anti coagulation. We advise symptomatic treatment um with compression leg elevation. Close follow up. Um He had progression of his symptoms, presumably related to whatever was going on there in the political Fassa and eventually had an M. R. I. Because of worsening pain which showed a likely hemorrhagic component. Um So this is a person where I'm going to bring it back for a close follow up. We'll have that discussion about continuing anti coagulation versus stopping it and I think with that I will stop. Thank you
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