A 45-year-old man presents with left calf swelling and tenderness for 2 days. He recently completed a 12-hour flight. There is no history of cancer, surgery, or prior thromboembolism. On examination the calf is tender and swollen compared to the contralateral side. Using the Wells criteria for deep vein thrombosis, what is the most appropriate next step?

• A Contrast venography as the definitive test
• B Immediate anticoagulation without imaging
• C D-dimer testing, with compression ultrasound if positive ✓
• D CT pulmonary angiography to rule out pulmonary embolism

Explanation

This patient has a modified Wells score likely in the moderate probability range (recent immobility, local tenderness, no alternative diagnosis). The standard algorithm is D-dimer testing first in moderate or low probability patients, proceeding to compression ultrasound only if D-dimer is positive. Contrast venography is invasive and not first-line. Empirical anticoagulation without imaging is inappropriate.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.