3. SUBJECTIVE
• Chief complaints: calf pain and swelling since
last week ,difficulty in walking
• History of present illness : Noticed swelling
of the right calf approximately 4 days ago. She
reported to the ED of her local hospital 1 day
after the onset of calf pain and swelling. Venous
Dopplers were performed and the patient was
told that she had a blood clot in her right leg.
4. • According to the condition she was given a
prescription for an injection and instructed to
follow-up with her PCP within the next 1 to 2
days. She failed to have the prescription filled
because her pharmacy did not have the drug in
stock. Because of increasing pain and
discomfort, she was seen by her physician this
morning who recommended hospitalization to
initialize therapy for her blood clot
5. • Previous medical history: previous DVT at
the age of 38, treated with warfarin for 3
months.
• Family history: Father died at 42 from MI;
mother alive at 71 with breast cancer diagnosed
5 years ago, s/p radiation/chemotherapy; sister
alive and well. No family history of venous
thromboembolic disease reported.
6. • Social history: Patient lives with her husband
and 16 y/o son; works in a department store as a
cashier. 24 pack-year smoking history; currently
smokes ½ to 1 ppd. (-) EtOH
• Meds: Raloxifene 60mg PO qd
• Multivitamin 1 tab PO qd
• Denies the use of herbal products
• RISK FACTORS:
• Smoking, SERM use, Previous DVT
7. OBJECTIVE
• +) Homan’s sign in right calf with no palpable cord
• Factor V Leiden Mutation – positive
• Venous compression Ultrasonography - RLE shows
non compressibility of the right posterior tibial vein
with no color flow. Normal compressibility and flow
demonstrated within the right common femoral and
iliac veins. LLE shows normal compression of the
deep venous system from the level of the common
femoral vein to the popliteal vein
8. ASSESEMENT
• From the subjective and objective evidence we
can confirm that patient is suffering from Acute
Deep vein thrombosis of the right posterior tibial
vein requiring initiation of anticoagulation.
Venogram not necessary due to positive
ultrasound results.
9.
10. • DEFINITION: Deep vein thrombosis (DVT) is
the development of thrombi in the deep veins of
the extremities or pelvis
• ETIOLOGY :The etiology is often multifactorial
(prolonged stasis, coagulation abnormalities,
vessel wall trauma). The following are risk
factors for DVT: Prolonged immobilization
days) Postoperative state Trauma to pelvis
and lower extremities Birth control pills,
high-dose estrogen therapy;
11. • Visceral cancer (lung, pancreas, alimentary tract,
GU tract)
• Age >60 yr.
• History of thromboembolic disease
• Recent travel (within 2 wk, lasting >6
hr) Smoking and abdominal obesity Central
venous catheter or pacemaker
insertion Superficial vein thrombosis, varicose
veins
12. Hematologic disorders (e.g., antithrombin III
deficiency, protein C deficiency, protein S deficiency,
heparin cofactor II deficiency, sticky platelet
syndrome, G20210A prothrombin mutation, lupus
anticoagulant, dysfibrin ogenemias, anti cardiolipin
antibody, hyperhomocyste inemia, concurrent
homocystinuria, high levels of factors VIII, XI, and
factor V Leiden mutation) Etiology Pregnancy and
early puerperium Obesity, CHF Surgery
requiring >30 min of anesthesia Gynecologic
surgery (particularly gynecologic cancer surgery)
13. PATHOPHYSIOLOGY
• Lower extremity DVT most often results
from
• Impaired venous return (eg, in immobilized
patients)
• Endothelial injury or dysfunction (eg, after leg
fractures)
• Hypercoagulability
14. • Upper extremity DVT most often results from
• Endothelial injury due to central venous catheters,
pacemakers, or injection drug use
• Upper extremity DVT occasionally occurs as part of
superior vena cava (SVC) syndrome or results from
a hypercoagulable state or subclavian vein
compression at the thoracic outlet. The compression
may be due to a normal or an accessory first rib or
fibrous band (thoracic outlet syndrome) or occur
during strenuous arm activity (effort thrombosis, or
Paget-Schroetter syndrome, which accounts for 1 to
4% of upper extremity DVT cases).
15. • Deep venous thrombosis usually begins in
venous valve cusps. Thrombi consist of
thrombin, fibrin, and RBCs with relatively few
platelets (red thrombi); without treatment,
thrombi may propagate proximally or travel to
the lungs
16. PLANNING
• The aims of treatment are:
• To prevent the clot spreading up the vein and
getting larger. This may prevent a large embolus
breaking off and travelling to the lungs (a
pulmonary embolus).
• To reduce the risk of post-thrombotic syndrome
developing.
• To reduce the risk of venous ulcers in the leg in
future. This can happen to people who have
developed post-thrombotic syndrome.
• To reduce the risk of a further DVT in the future
17. • DAY 1-5
• Enoxaparin 122U (1mg/kg)
• SC every 12hrs for 5 days
• Warfarin 5mg orally
• DAY 6
• Discontinue LMWH
• Patient has to continue on warfarin therapy for
at least 1 yr due to prior DVT
18. • Enoxaparin:
• MOA: Enoxaparin binds to and potentiates
antithrombin (a circulating anticoagulant) to
form a complex that irreversibly inactivates
clotting factor Xa.
• ADR’S: bleeding,confusion,pain,diarrhoea.
19. Patient counselling
• Patients are advised to wear compression
stockings
• Walking regularly but raising the legs while its
resting.
• Avoid long periods of immobility
20. • When you travel on long plane, train, car or
coach journeys, you should have little walks up
and down the aisle every now and then. Try to
exercise your calf muscles whilst sitting in your
seat. (You can do this by circling your ankles,
getting into a 'tiptoe' position and lifting your
toes off the floor whilst keeping your heels on
the ground.) You should aim to stay well-
hydrated and avoid alcohol and sleeping
medications
21. • People who are overweight have an increased
risk of DVT. Therefore, to reduce your risk, you
should try to lose weight.
