
A 57-Year-Old Woman with Calf Pain: The Role of POCUS in Primary Care
A 57-year-old woman with a distant history of breast cancer and lower extremity DVT presents to her primary care physician complaining of two days of persistent right calf pain after a six-hour flight. The pain is constant, non-radiating, and worsens with movement. She denies recent surgeries, chest pain, or shortness of breath. On examination, her right calf shows mild tenderness but no swelling or redness. Her vital signs are normal, and her Wells score for DVT is 1, indicating moderate risk.
With no immediate access to high-sensitivity D-dimer results or comprehensive vascular ultrasound study, 3-point compression point-of-care ultrasound (POCUS) is performed at the bedside. The proximal veins of the right leg are compressed at the following 3 regions:
- Inguinal region:
- Common femoral vein
- Junction of common femoral vein and saphenous vein
- Confluence of deep femoral and femoral veins
- Mid-thigh region: femoral vein
- Popliteal region: popliteal vein
See Figure 1 for a quick guide.

A representative clip at the junction of the right common femoral and saphenous veins is provided below. What do you see? Does she have a DVT?

The proximal veins are fully compressible, ruling out a proximal DVT. POCUS also excluded other possible causes of her symptoms, such as a Baker’s cyst.
Three days later, D-dimer results returned negative, confirming the absence of DVT.
Management and Outcome: The patient was advised to stay hydrated, perform gentle calf stretches, and use ibuprofen as needed for pain. Her symptoms resolved within a week without complications.
Discussion: This case highlights how POCUS simplifies DVT evaluation, especially when traditional imaging or lab tests are not immediately available. While a high-sensitivity D-dimer test alone could have ruled out a DVT in this moderate-risk patient, the immediate reassurance provided by POCUS enhanced patient care, efficiency, and satisfaction.
Evidence and Guidelines:
- Wells Score and DVT Risk Stratification: Patients with a low (-2 to 0) and moderate Wells score (1 to 2) and a negative high-sensitivity D-dimer have a <1% probability of DVT, eliminating the need for further testing. [1,2]
- POCUS Sensitivity: POCUS shows sensitivity of up to 96% for detecting proximal DVT when performed by trained clinicians. [3]
- Cost Savings: Using POCUS in primary care can save over $1,800 per patient compared to emergency department visits. [4]
- Additional Revenue: Unilateral lower extremity POCUS is reimbursed at $116 using the 2024 Medicare global physician fee schedule. [5]
Patient Impact: For this patient, POCUS reduced uncertainty, avoided unnecessary referrals, and saved healthcare costs, all while addressing her concerns promptly and effectively.
POCUS is a valuable diagnostic tool in primary care, improving efficiency, reducing costs, and enhancing patient satisfaction. Its integration into routine practice can revolutionize how primary care providers manage conditions like a DVT. To further learn how to integrate POCUS into your practice, refer to this sample clinical pathway for a DVT rule-out in primary care and urgent care settings.
References
- MDCalc. Wells' Criteria for DVT. Accessed: December 16, 2024. [Online] Available: https://www.mdcalc.com/calc/362/wells-criteria-dvt
- Kearon C, de Wit K, Parpia S, Schulman S, Spencer FA, Sharma S, Afilalo M, Kahn SR, Le Gal G, Shivakumar S, Bates SM, Wu C, Lazo-Langner A, D'Aragon F, Deshaies JF, Spadafora L, Julian JA. Diagnosis of deep vein thrombosis with D-dimer adjusted to clinical probability: prospective diagnostic management study. BMJ. 2022 Feb 15;376:e067378. doi: 10.1136/bmj-2021-067378.
- Pomero F, Dentali F, Borretta V, Bonzini M, Melchio R, Douketis JD, Fenoglio LM. Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost. 2013 Jan;109(1):137-45. doi: 10.1160/TH12-07-0473.
- UnitedHealth Group. (2019). The high cost of avoidable hospital emergency department visits. UnitedHealth Group. Accessed: December 16, 2024. [Online] Available: https://www.unitedhealthgroup.com/content/dam/UHG/PDF/2019/UHG-Avoidable-ED-Visits.pdf
- “2024 Medicare Fees for Diagnostic and Procedural POCUS for Urgent Care Centers.” Accessed: December 16, 2024. [Online] Available: https://www.hellosono.com/downloadables-1/urgent-care-2024-fees-pocus-exams
About the Author
Dr. Havryliuk is an emergency physician with over 15 years of clinical point-of-care ultrasound (POCUS) experience, a past Emergency Ultrasound Director at Brooklyn Hospital in NY, and the founder of Hello Sono. She is on a mission to empower clinicians with POCUS to take better and more efficient care of their patients by addressing two key barriers, lack of competency and infrastructure.
LinkedIn: https://www.linkedin.com/in/tatiana-havryliuk-md/
Email: tatiana@hellosono.com
*POCUS images and graphics provided courtesy of Hello Sono.