Question

A 51 year old supermarket cashier has had worsening pain and tenderness of her left leg. Her symptoms have been worsening for the past two days, ever since she had to work three consecutive days of "double shifts" due to a co-worker's absence. Medications include lisinopril for hypertension and hormone replacement therapy for hot flashes. Physical examination shows an obese female with temperature 38.1 C (100.5 F), pulse 88, BP 136/84, and respirations 14/min. There are numerous prominent varicose veins on the legs bilaterally. The left leg has a 6 inch (15 cm) linear area of erythema and edema on the medial aspect of the knee and calf, with a palpable, nodular, cordlike structure located just underneath the skin. Doppler ultrasonography is performed on both legs and shows a single thrombus extending from the middle to distal saphenous vein on the left. Which of the following is the most appropriate next step in management of this patient's condition?

A. Rest, elevation, non-steroidal anti-inflammatory agents, and heat
B. Enoxaparin
C. Warfarin
D. Spiral CT of the chest
E. Placement of inferior vena cava filter

Answer 1

The most appropriate next step in managing the patient's superficial thrombophlebitis, secondary to varicose veins, is the initiation of anticoagulation therapy with Enoxaparin (choice B). Enoxaparin acts quickly and is the primary treatment to prevent thrombus extension. Supportive treatments are adjuncts but not the primary intervention.

Step-by-step explanation:

The patient described in the scenario appears to be suffering from lower limb superficial thrombophlebitis due to varicose veins, which are common in individuals who stand for prolonged periods, such as a supermarket cashier. Given the presence of a confirmed thrombus in the saphenous vein, the most appropriate next step in management is the use of anticoagulation therapy. The correct choice is B. Enoxaparin, which is a low-molecular-weight heparin used in the initial treatment of venous thromboembolism. Enoxaparin is preferred over warfarin for immediate anticoagulation due to its faster onset of action. Warfarin may be initiated concurrently and then continued after enoxaparin for a longer duration of therapy. Supportive measures like rest, elevation, and non-steroidal anti-inflammatory agents can also be used to manage symptoms, but the priority is to initiate anticoagulation. A spiral CT of the chest would be considered if there were signs of pulmonary embolism, and placement of an inferior vena cava filter is generally reserved for cases where anticoagulation is contraindicated or has failed.