SOPE formate for deep vain thrombosis case related study

1. SOAP FORMAT ON DVT & PE
From Prolonged Television
Watching
PRESENTED BY : Premal Vaghela

2. PATIENT’S DETAILS
• Name : ABC
• Age : 59 years
• Gender : Female
• Weight : -
• Height : -
• BMI : 51 kg/m²
• Mental status : -

3. HISTORY OF PRESENT ILLNESS
• She has past medical history of obesity , autoimmune hepatitis, and
osteoporosis presented to emergency department (ED).
• Complaining of right calf pain and swelling.
• She had no history of previous venous thromboembolic disease.
• The patient stated that the pain started after watching television for
eight continuous hours.
• The following day, she noted persistent right calf pain.
• However, she was particularly engaged in national convention coverage
and watched television continuously for approximately eight more
hours.

4. Cont….
• She recalls that she did not take any breaks from watching the convention
in fact she stated she only moves from the chair once to go to the
bathroom.
• After two days of mild throbbing pain and swelling , she decided to have
family members drive her to ED.

5. PAST MEDICAL HISTORY
• The patient has a history of immune hepatitis which had been stable for
years , treated with Imuran.
• Hiatal hernia (hiatal hernia occurs when the upper part of your stomach
bulges through the large muscle separating your abdomen and chest
(diaphragm).
• Sleep apnea requiring nighttime continuous positive airway pressure
(CPAP) machine.
• Osteoporosis.

6. PAST SURGICAL HISTORY
• She had no previous no surgeries other than a left wrist surgery 20 years
previously.
•PAST SOCIAL HISTORY
• She never smoked and She dose not drink alcohol.

7. FAMILY HISTORY
• The family history was notable for Paget’s disease (A disease that disrupts
the replacement of old bone tissue with new bone tissue)
• She denied any family history was
thromboembolism , bleeding , or clotting disorders

8. PAST MEDICATION HISTORY
• Other than Imuran (Azathioprine ; is an immunosuppressive medication)
and Fosamax (Alendronic acid ; is a bisphosphonate medication used to
treat osteoporosis and Paget's disease of bone) .

9. S : SUBJECTIVE

10. PATIENT’S COMPLAINTS :
• Chief complain : Persistent right calf pain
• She was having occasional dizziness and dyspnea on exertion

11. In patients undergoing general
and abdominal-pelvic surgeries,
the Caprini score is used to
assess the risk of DVT.
Interpretation of the Caprini
risk score
The Caprini score is calculated
by adding the scores of all
factors present in the patient.
The Caprini score is interpreted
in the following way:
Score 0–1: Low risk of VTE
Score 2: Moderate of VTE
Score 3–4: High risk of VTE
Score ≥5: Highest risk for VTE.

12. O : OBJECTIVE

13. EXAMINATION
GENERAL EXAMINATION:
• Blood pressure: 115/70 mmHg
• Heart rate: 125 bpm(60-100 bpm)
• Respiratory rate: 18 bpm(12-16
bpm)
• Temperature: 97.1 F
• Oxygen saturation :96%
SYSTEMIC EXAMINATION:
• Cardiac: no murmurs
• Pulmonary: Breath sounds were
diminished bilaterally.
• Liver function tests were
normal.

14. LAB INVESTIGATIONS

15. OTHER DIAGNOSTIC TEST
• Her pain score was 5/10 and she was anxious.
• On physical exam, the patient appeared mildly anxious with obvious
swelling of her right calf. There was moderate right calf tenderness
with +1 pitting edema(least severe type of edema).

16. Computed Tomography Angiography (CTA) of the chest was positive for
bilateral pulmonary emboli specifically right upper lobe, right middle lobe,
and left lower lobe segmental thrombi.

17. Ultrasound revealed occlusive thrombus to right
popliteal and right posterior tibial vein.

18. CONT..
• Anticoagulation with Thrombolytic was initiated in the ER with IV
heparin.
• She had a 2D echocardiogram that revealed mild right ventricular
dysfunction, mild tricuspid regurgitation, and an elevated pulmonary
artery pressure of 25–30 mmHg at rest.
• The pulmonary/critical team was consulted and given that the patient
had normal troponin, BNP, and oxygenation on RA.
• Additionally, the patient’s tachycardia improved with IV fluids.

19. A: ASSESSMENT

20. DIAGNOSIS
• On the basis of history , complaints of patient, Laboratory parameters
and other diagnostic test, we may conclude that patient is suffering
from DVT & PE from prolonged Television watching.

21. ETIOLOGY
• Have been inactive or immobile for long periods of time due to bed rest
or surgery.
• Have a personal or family history of a blood clotting disorder, such as
deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Have a history of cancer or are receiving chemotherapy.
• Sit for prolonged periods.
• Smoking

22. NEED OF THERAPY
• To Reduce morbidity and mortality rates.
• To Resolve complaints of patient.
• To improve overall health status of patient.
• To prevent further complication of the disease.
• To improve patient’s quality of life.

23. ASSESSMENT OF STANDARD THERAPY

25. ASSESSMENT OF CURRENT THERAPY

26. 1. Drug: Heparin
 Class: Anticoagulants
 Dose: -
 Frequency: -
 Route of administration: IV
 Indication: DVT & PE, Acute Coronary Syndromes

27. CONT..
M/A: Mechanism for low dose: Inactivates factor Xa and inhibits conversion of prothrombin to
thrombin
Mechanism for high dose: Inactivates factors IX, X, XI, and XII and thrombin and inhibits
conversion of fibrinogen to fibrin
• Also inhibits activation of factor VIII
A/E: Heparin-induced thrombocytopenia, possibly delayed (10-30% ), Mild pain ,Hemorrhage
,Injection site ulcer (after deep SC injection), Increased liver aminotransferase, Anaphylaxis,
Immune hypersensitivity reaction, Osteoporosis (long-term, high-dose use)
Contraindication : History of pentosan polysulfate-induced thrombocytopenia (HIT) (with or
without thrombosis),Uncontrolled, active bleeding (except DIC), Known hypersensitivity to heparin
NOTE : This drug is rational.

28. 2. Drug: rivaroxaban
 Class: Anticoagulants, Factor Xa Inhibitors
 Dose: -
 Frequency:-
 Route of administration:
 Indication: stroke, atrial fibrillation, DVT and /or PE, venous
thromboembolism

29. CONT..
• M/A: Factor Xa inhibitor that inhibits platelet activation by selectively blocking the
active site of factor Xa without requiring a cofactor for activity ,Blood coagulation
cascade is dependent on the activation of factor X to factor Xa via the intrinsic and
extrinsic pathways, which play a central role in the blood coagulation cascade.
• A/E: Hematoma (<3%),Back pain (2.9%),Wound secretion (2.8%),Abdominal pain
(2.7%),Dizziness (2.2%),Pruritus (2.1-2.2%),Pain in extremity (1.7%), Insomnia
(1.6%),Anxiety (1.4%), Blister (1.4%),Fatigue (1.4%), Muscle spasm (1.3%),Syncope
(1.2%), Muscle spasm (1.2%),Depression (1.2%) ,Major bleeding
• Contraindication : Hypersensitivity ,Active pathological bleeding, Patients who have had
transcatheter aortic valve replacement.
NOTE: This drug is rational

30. PHARMACOKINETICS

31. P: Planning

32. Discharge medication
• Not given

33. GOAL OF THERAPY
 GENERAL GOALS
-To reduce the morbidity and
mortality rates.
- To improve patients quality of
life.
- To prevent further
complications.
 PATIENT SPECIFIC GOAL
- To provide the best possible
treatment to patient.
- To overcome the complaints of
the patient.
- To give the best treatment
whichever is possible.

34. MONITORING THERAPY

35. Drug Therapeutic monitoring Toxicity monitoring
Rivaroxaban The rivaroxaban assay
measures circulating levels of
rivaroxaban based on its
anticoagulant action. Measuring
rivaroxaban concentration will allow
dose adjustment to prevent too
much anticoagulant effect and risk
for bleeding or no anticoagulant
action and inadequate therapy.
Testing for Protein C, antithrombin
and fibrinogen activity should be
accurate on rivaroxaban. according
to bleeding risk - restart the drug 24
– 72 hours after a procedure.
-

36. DRUG-DRUG INTERACTION

37. POINTS TO PHYSICIAN
• There are improper documentation.
• Patient’s height and weight are not measured.
• No measurement of lipid levels, uric acid levels and thyroid hormone levels
is carried out.
• Keep the patient well hydrated as there are more chances of dehydration
because of blood loss due to injury and also it will be helpful for
improvement in patient’s blood pressure

38. POINTS TO PATIENT
 DISEASE RELATED:
• PE : Pulmonary embolism is when a
blood clot stuck in an artery in the
lung and blocks blood flow to the
lung.
• It usually arises from a thrombus
(clot) that originates in the deep
venous system of the lower
extremities.

39. DRUG RELATED
1) HEPARIN
Patient / Family education:
• Caution patient to avoid IM injections.
• Advise patient to avoid activities that carry risk of injury. Inform patient of potential for hair loss.
• Explain that this effect may occur several months after heparin therapy is started.
• Inform female patients that menstruation may be somewhat increased and prolonged.
• Advise patient that smoking and alcohol may alter response to heparin, and therefore, are not
advised.
• Inform patient that abrupt withdrawal of heparin may precipitate increased coagulability.

40.  ADMINISTRATION AND STORAGE
• Heparin is strongly acidic and is incompatible with many drugs.
• Avoid mixing any drug with heparin unless specifically advised by health care provider.
• Do not aspirate patient to check entry into blood vessel. Apply gentle pressure to puncture site for
about 1 min; do not massage. Rotate injection sites frequently and keep record.
• IV administration may be given undiluted over 1 min.
• For IV infusion, dilute prescribed amount in 0.9% Sodium Chloride for Injection, D5W, or Ringer's
Injection solution.
• Use infusion pump to ensure accuracy. Store at room temperature. Protect from freezing.
• Inspect all preparations for particulate matter prior to administration.
• Also inspect for discoloration; note that slight discoloration does not alter potency.

41. 2) rivaroxaban
Patient / Family education:
• If you have difficulty swallowing the tablet whole, talk to your doctor
about other ways to take .
• Do not stop taking XARELTO without talking with your doctor first.. tell
your doctor if you go for any surgery,
• Take with or without food.
• Inform your healthcare provider if you have any symptoms like headache ,
pain, swelling or discomfort dizziness , nose bleeding bleeding of gums

42.  ADMINISTRATION AND STORAGE
• Keep all medicines out of the reach and sight of children.
• Store in a cool, dry place, away from direct heat and light.
• Store at room temperature between 68° F to 77°F (20° to 25° C).

43. LIFE STYLE MODIFICATION
• Stop smoking
• Loose weight if you are over weight and try to maintain healthy weight.
• Limiting the amount of time you spend sitting
• Exercise regularly mainly walking and move your legs to prevent the blood from
pooling.
• Avoid wearing tight-fitting clothes for extended periods
• Drinking lots of fluids
• Consuming foods that act as natural blood thinners to reduce the risk of developing
blood clots, such as vitamin E, ginger, cayenne pepper, garlic, turmeric, and cinnamon.

44. DIETARY MODIFICATIONS
• Limit unhealthy fats and sodium.
• Avoid sugary and processed foods.
• Eat more fruits and vegetables.
• Choose whole grains.
• Choose low-fat protein sources.
• Limit caffeine and alcohol.
• Healthy fats like olive and canola oil.

45. FOLLOW-UP AND REVIEW
• The patient was hemodynamically stable upon leaving the emergency
department for the ICU .
• She was transitioned over to novel anticoagulant rivaroxaban for
following day ( hospital day number 1 ) and was discharged home
three day later without complication.

46. REFERENCES
• Joseph T. DiPiro, Pharmacotherapy: A Pathophysiologic Approach, 10th
Edition, Mc Graw Hill Education.
• David S. Tatro, A to Z Drug Facts, Facts and Comparison.
• Leslie Kane (2018) Medscape, Available at www.Medscape.com (Last
Accessed on: 10th January 2020).
• https://www.webmd.com/dvt/foods-help-prevent-dvt.
• https://heartofdixieveincenter.com/lifestyle-choices-can-reduce-risk-
blood-clots/