A junior doctor realises dogged adherence to guidelines is not always the wisest course

Barbara is a 65-year-old woman with scleroderma.

She is a long-term patient of the practice and presents with a 1cm diameter ulcer on her left calf, which is tender.

There is no discharge or erythema, and it is not infected. There are skin changes consistent with scleroderma (dry, thickened skin, loss of hair, hypo- and hyper-pigmented areas), and marked varicose veins.

The immediate working diagnosis is a venous ulcer, with suspicion of DVT. Barbara recently had a few days' hospital admission for an unrelated complaint.

DVT was confirmed on venous duplex ultrasonography — identifying thrombosis of the left posterior tibial vein, plus extensive thrombosis of the long saphenous vein.

Initiating anticoagulation
Following a discussion with Barbara and her rheumatologist, it was agreed anticoagulation should be initiated immediately — warfarin, with low