A 45-year-old male who underwent lower-extremity orthopedic surgery 10 days ago presents to the emergency department with a swollen, painful right calf. Vital signs are: temperature 98.2 °F (36.8 °C), heart rate 84/min, blood pressure 128/78 mm Hg, respiratory rate 16/min, and SpO₂ 98 % on room air. He denies chest pain or shortness of breath. Based on this presentation, what is the most appropriate next step in management?
Obtain a D-dimer assay to rule out deep vein thrombosis.
Elevate the extremity and apply a warm compress.
Begin therapeutic anticoagulation to prevent clot propagation.
Order duplex (compression) ultrasonography of the affected leg.
His recent surgery and unilateral calf swelling give him a likely pretest probability of lower-extremity DVT under the Wells criteria. Guidelines from the American Society of Hematology and American College of Physicians recommend compression (duplex) ultrasonography as the first-line diagnostic study for patients with an intermediate-to-high pretest probability. A D-dimer is useful only to rule out DVT in low-risk patients, and empiric anticoagulation is generally reserved for situations where diagnostic imaging will be significantly delayed. Elevation and warm compresses provide comfort but neither confirm nor treat DVT.
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