68yo man presented to ED with a tight swollen left calf.
He had a history of thrombophilia and takes clexane on long haul flights. This presentation had no obvious precipitant,
On examination, there was obvious asymmetry in calf size and venous engorgement on the left. HR 90 regular, sats 100, BP 145/80. He stated he had no respiratory Sx or CP and felt otherwise well.
While waiting for formal US we did an ED one.
CFV in transverse: mobile non occlusive thrombus seen in the lumen (annotated below)
Longitudinal view of FV with floating thrombus: pt's cough caused vein to dilate demonstrating just how mobile the thrombus was!!!!!!!
The patient was started on an anticoagulant dose of clexane and further questioning (more like suggestive questioning) led to a hx of maybe SOB, maybe feeling like he was coming down with a cold.
CTPA revealed bilateral proximal emboli.
He was kept in bed until transferred to the ward.
I know we often feel as if ED DVT US doesn't make a difference because we get a formal US anyway: so what's the point. But I think it is still useful to know if the patient has a very proximal thrombus like this. In this man's case it changed his management from sitting in the WR waiting for an US which could take hours to full anticoagulation, further investigation and admission to the ward within minutes.