“My leg’s swollen and sore — I think I’ve pulled something”

A unilateral swollen, warm, tender calf worsening over days — especially with recent long-haul flight/immobility and oestrogen (HRT) — is a deep vein thrombosis until proven otherwise, NOT a pulled muscle, and usually not cellulitis (a spreading red area, often with a skin break/fever). Manage with a structured two-level Wells DVT score guiding a same-day pathway (NICE NG158): urgent D-dimer and/or proximal-leg Doppler ultrasound, with interim anticoagulation if the scan can’t be done promptly — never an anti-inflammatory gel or antibiotics down the phone. Critically, screen for PULMONARY EMBOLISM (breathlessness, pleuritic chest pain, haemoptysis, syncope, tachycardia); here she has breathlessness plus pleuritic pain, so she needs same-day hospital assessment for suspected PE (NICE NG158 PE Wells; CTPA immediately if PE is likely, interim anticoagulation if delayed), 999 if acutely unwell. The examinable hidden agenda is minimisation driven by being overwhelmed (a carer who can’t take time off) and fear that her HRT — which transformed her menopause — will be blamed and stopped; draw out the risk factors, address the HRT honestly (pause it now pending investigation — BNF; oral oestrogen is a risk factor, transdermal at standard doses is not — NICE NG23; future choice with specialist advice if VTE is confirmed) without blame, acknowledge the caring barriers while holding the urgency, and safety-net PE red flags to 999.