65-Year-Old Woman With Swelling of the Right Lower Limb

65-year-old woman presented to the emergency de­ partment for evaluation of pain and swelling of her right lower extremity, which was associated with warmth and tenderness. She denied experiencing any recent long­ distance travel, trauma, estrogen use, fever, chest pain, dyspnea, hemoptysis, syncope, or previous deep venous thrombosis. She had a 2-month history of increasing dysuria, urinary frequency, nocturia, urge incontinence, and intermittent vaginal bleeding. In addition, she had ex­ creted no urine for 24 hours. The patient denied having any flank pain, hematuria, or passage of gravel in her urine. She had taken no analgesics nor been exposed to any radiologic contrast media. The patient's history was notable for several episodes of pyelonephritis during pregnancy, pelvic inflammatory dis­ ease, vulval papillomas (one of which demonstrated in situ carcinoma on excision 40 years previously), and gastro­ esophageal reflux disease. She was a long-term smoker but consumed no alcohol. There was no family history of renal disease, thromboembolism, or cancer. On examination, the patient appeared ill and pale. Her temperature was 37.2°C, pulse rate was 80/min, blood pressure was 100/60 mm Hg with no orthostatic drop, and respirations were 20/min. She had no adenopathy, goiter, or rash. Findings on a breast examination were normal. The apex beat was not displaced, the heart sounds were normal with a soft systolic murmur at the base, and there was no pericardial friction rub. Diffuse expiratory rhonchi were detected in the chest. Her abdomen was soft, nondistended, and without tenderness or bruits. The bladder was not palpable. Her right lower limb was swollen, warm, and tender up to the mid thigh with no cords palpable. Initial laboratory results (reference ranges shown paren­ thetically) were as follows: hemoglobin, 5.9 g/dl, (12.0­ 15.5 g/dL); mean corpuscular volume, 80 tL (81.6-98.3 Il.); leukocytes, 11.5 x 10 9!L (3.5-10.5 x 10 9!L); platelet