New Calf Swelling on Day 5 After Stroke Rehabilitation
Mrs. N., a 58-year-old woman, is day 5 after a left middle cerebral artery infarct. She is in inpatient rehabilitation at a MOH hospital. She has dense right hemiplegia, neglect, and a NIHSS of 12 on admission; she is now mobilising with a tilt table and two assistants. During morning therapy she reports new right calf pain. You note a 3 cm circumference difference compared with the left calf, warmth, and tenderness along the posterior calf. Her heart rate is 104 beats/min, blood pressure 138/82 mmHg, SpO2 94% on room air, and temperature 37.4°C. She is on enoxaparin 40 mg subcutaneously daily, but the nurse says the last two doses were withheld because of a planned hip X-ray and then a cancelled procedure. The family asks you to continue standing practice because 'walking will prevent clots.' The rehabilitation physician is in theatre and will not review for 3 hours.
1. What is your differential diagnosis and risk assessment for this patient?
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- The leading concern is deep vein thrombosis (DVT) of the right leg. The findings of unilateral calf swelling, a 3 cm difference, warmth, tenderness, recent immobility from hemiplegia, and missed enoxaparin doses all increase the probability. The Wells score for DVT would be high because of paralysis/immobility, localized tenderness, calf swelling, and a measured calf difference; the missed anticoagulation further raises concern.
- Other possibilities include a muscle tear or hematoma after therapy (possible with anticoagulation), cellulitis, a Baker cyst, or dependent edema. Cellulitis is less likely with no fever and only mild temperature elevation, but cannot be excluded.
- A normal D-dimer would not reliably exclude DVT here because the patient is post-stroke and may have elevated D-dimer from other causes; in a high-probability patient, urgent compression ultrasound is the appropriate test.
- I would also screen for pulmonary embolism: tachycardia at 104 beats/min and SpO2 94% are nonspecific but warrant closer monitoring for chest pain, sudden dyspnea, or further desaturation.
2. What immediate actions and therapy restrictions should you take?
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- Stop mobilisation and standing practice immediately. Do not massage the calf or perform vigorous passive movements; both could dislodge a clot and increase PE risk.
- Notify the rehabilitation physician or on-call medical team now, even if the physician is in theatre. Request urgent compression ultrasound and review of anticoagulation. If the physician cannot attend within a safe timeframe, escalate to the on-call consultant or rapid-response team.
- Check the anticoagulation record and clarify why enoxaparin was withheld. Do not administer extra anticoagulant without a medical order. If the patient has signs of PE or becomes unstable, treat as an emergency.
- Keep the leg elevated at rest if comfortable, but avoid compression stockings or bandaging until DVT is excluded and a plan is ordered.
- Document the findings, time of escalation, and advice received. The family should be told that walking does not prevent a clot and may be unsafe until the leg is assessed.
3. How would you communicate with the family and document the episode?
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- Explain in plain language that the new swelling and pain may indicate a clot, and that continuing standing practice could be dangerous until an ultrasound is done. Acknowledge their wish to keep her active, but state that safety comes first.
- Avoid blaming the missed doses; say that the medical team is reviewing the blood thinner and the leg. Tell them what to watch for: sudden breathlessness, chest pain, coughing blood, or fainting.
- Document: calf circumference and side, warmth, tenderness, heart rate, SpO2, temperature, missed enoxaparin doses, mobility status, time the physician was notified, instructions received, and family discussion.
- Record that mobilisation was withheld pending imaging. This documentation protects the patient and shows that the clinical deterioration was recognised and escalated.