Physician's Assistant

Sdec Mon 21 July 2025 14:12

Last Modified: 37 weeks ago

MRN:

Content:

Presenting Complaint:
Right leg DVT

Past Medical History:
• Previous DVT and pulmonary embolism (provoked by IV drug use)
• Ex-IV drug user (clean for 10 years)
• Current smoker

Diagnosis:
Right popliteal vein DVT

I had the pleasure of meeting Mark Berbery in Same Day Emergency Care today.

Mr Berbery presented with right leg swelling and pain. He has a significant past medical history of previous DVT and pulmonary embolism which were provoked by IV drug use. He has been clean from heroin for 10 years but continues to smoke cigarettes.

On examination, his right leg was visibly swollen, tender, and erythematous throughout. Previous injection sites were visible. He was mobilising with some difficulty due to pain and swelling.

Ultrasound doppler confirmed acute non-occlusive thrombus throughout the right popliteal vein. A subsequent scan showed no above-knee DVT but adequate visualisation of calf veins was not possible due to swelling, therefore calf vein propagation could not be excluded.

He was commenced on Rivaroxaban following his GP consultation prior to the scan and reports good compliance with daily dosing. He has been advised to continue anticoagulation for at least 6 months.

Investigations:
Ultrasound lower limb doppler July 2025: Acute non-occlusive thrombus throughout right popliteal vein
DVT scan 10th July 2025: No above knee DVT, calf veins inadequately visualised due to swelling

Plan:
1. Continue Rivaroxaban anticoagulation for minimum 6 months
2. DVT clinic telephone follow-up in coming months
3. Patient education regarding DVT management provided
4. No further hospital follow-up required unless complications arise

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Summary:

Investigations:

Sdec Mon 21 July 2025 14:12

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