Transcript Case presentation

Case presentation
98.5.6
Patient profile
Name:邱X四
Age: 64
Gender: male
Chart number: 02251392
Admitted to our ward on 98.5.1
Chief complaint
Left lower limb swelling for about 2 days.
Present illness
This 64-year-old man lived in nursing home and has
been a patient of gastric cancer s/p operation in MK95,
old stroke in MK93 with vertebral-basilar insufficiency,
benign prostate hyperplasia, hypertension and
depression.
He got regular followed up in our Urology OPD to deal
with benign prostate hyperplasia.
Besides, recent urinary tract infection episode was noted
(urine culture: Providencia stuartii) due to decreased
urine amount and under antibiotic treatment with cravit
from our urology OPD since 4/27.
According to his family, he complained of unsteady gait 2
days ago and left lower limb swelling and firmness was
noted by family. Soreness and numbness were also told
by patient. he denied pain or hot sensation. The color of
left leg was slight purple.
He denied similar episode before and recent lower limb
trauma. His daily activity was normal.
There was no fever, chills, body weight change,
orthopnea, paroxysmal noctual dyspnea, shortness of
breath, chest pain, nausea, vomiting, abdominal pain or
diarrhea. Cough with whitish sputum was noted for many
years.
Due to this problem, he took diuretics for 2 days but no
obvious effect. Then he was taken to our ER for help.
In our ER, his consciousness was alert and oriented. On
physical examination, his vital sign was within normal
limit. Lab investigation showed elevated D-dimer level.
Deep venous thrombosis was suspected so he was
admitted to our ward for further management.
Past history
Gastric fundus GIST post OP
Old stroke with chronic dizziness since MK93
Hypertension, stop drug for 2 years
History of peptic ulcer
History of reflux esophagitis
Benign prostate hyperplasia
Depression
Operation history:



gastric fundus gastrointestinal stromal tumor post wedge
resection of gastric fundus tumor on 2006.11.8
Gallbladder stone with acute cholecystitis post laparoscopic
cholecystectomy in MK91
BPH post TUIP+PPS in 2007/12
Personal history
Cigarette Smoking : 3-4PPD for about 20
years,quit for 6-7 years
Alcohol : denied
Contact history : Nil
Travel history : Nil
Allergy history:denied
Current medication

Urology OPD
Sronin S.C. 1 ＊ TID PC
Wecoli 1 ＊ TID PC
Harnalidge 1 ＊ HS
Cravit 1 ＊ QDAMPC
rasitol 1 ＊ PRN

Psychi OPD
Eurodin 1# hs, kinxetine 2# hs, stilnox 1# hs

Neuro OPD
Xanax 1# bidpc, dulcolax 2# hs, nobby 1# om, MgO 1# tidpc
Family history


DM and hypertension
Denied inherited thrombophilia
Physical examination
Conscious: Alert, E4V5M6
Vital sign

BP:130/75mmHg, PR:78bpm, RR:18pm, BT:36.6 degree
HEENT

Conjunctiva: not pale, sclera: not icteric
Neck

supple, lymphadenopathy(-) jugular vein engorgement(-)
Chest: symmetric expansion


breathing sound: Clear
heart sound: regular, normal S1/S2, no S3/S4
Abdomen




Soft & flat, Bowel sounds: normoactive
Muscle guarding(-), tenderness(-), rebounding pain(-)
Liver/spleen: impalpable
CV angle knocking pain: (-/-)
Lower limbs


left lower limb swelling (thigh circumference=52.4cm) and mild
red-purple colored, but no pain, tenderness and local heat, no
superficial vein distension
Pre-tibial pitting edema in left leg
Skin

petechiae/hematoma(-), bedsore/wound(-), skin rash(-)
Urine routine
Lab data
CBC/DC
Glucose
-
Bilirubin
-
biochemistry
Ketone
+/-
GOT 17
SG
1.01
Baso
0.5
WBC 12.37 Mono
5.4
GPT
14
OB
-
RBC
6.32
Lymph
21.4
BUN
10.4
pH
6.0
Hgb
17.2
PT
9.9
Crea 1.53
Protein
30
CK
52
Urobilinogen 1.0
Glu
130
Nitrite
+
Hct
51.5
PTc
10.7
MCV 81.5
INR
1.0
UA
5.9
Leukocyte
1+
PLT
214
PTT
20.9
Na
139
RBC
0-2
Neut
72.2
PTTc
28.9
K
3.1
WBC
2-5
Cl
102
Epi
0-2
Crystal
-
cast
-
eosin 0.5
D-Dimer 879
CRP 5.4
Impression
Left lower limb deep venous thrombosis
Urinary tract infection, improved
Gastric cancer s/p operation
Hypertension
Benign prostate hyperplasia
Plan
Heparin 5000U IV bolus, then 20000U +
N/S 500ml keep pump 20ml/hr
Follow up PTT
Arrange cardiac echo and CTA of bilateral
lower limbs
Check protein C, protein S, lupus
anticoagulant
5/1 CXR
PTT follow up
5/1
1348
5/2
2314
0710
5/3
1200
1845
0700
5/4
1300
1830
0000
0800
PT
9.9
9.9
PTc
10.7
10.5
INR
1.0
1.0
PTT
20.9
41.1
42.1
39.0
40.7
49.9
37.3
36.9
40.4
52.8
PTTc
28.9
28.9
28.9
28.7
28,7
28.7
29.0
29.0
29.0
28.3
5/4

cardiac echo
Adequate LV systolic function but impaired diastolic function
Mild TR with pulmonary hypertension and estimated
RVSP:33.55 mmHg
AV sclerosis

Add coumadin 0.5# QD/AMPC
5/5

CTA
Deep venous thrombosis
Approximately 2/3 of symptomatic VTE
events are hospital acquired


Residents of skilled nursing facilities are
especially vulnerable
DVT occurs about 3 times more often than PE
Risk factor
History of immobilization or
prolonged hospitalization/bed
rest
Recent surgery
Obesity
cigarette smoking
Prior episode of VTE
Lower extremity trauma
Malignancy
Use of OCP or HRT
Pregnancy or postpartum
status
Stroke
COPD
Clinical manifestation
Classic symptoms of DVT include swelling, pain,
and discoloration in the involved extremity

not necessarily a correlation between the location of
symptoms and the site of thrombosis.
Physical examination

a palpable cord (reflecting a thrombosed vein), calf
pain, ipsilateral edema or swelling with a difference in
calf diameters, warmth, tenderness, erythema, and/or
superficial venous dilation.
differential diagnosis
Cellulitis
Superficial vein phlebitis
Chronic venous insufficiency : the most common
cause of chronic unilateral leg edema
Lymphedema
Popliteal (Baker's) cyst : Sudden, severe calf
discomfort
Knee abnormality
Drug-induced edema
Calf muscle pull or tear
The major adverse outcome of DVT:
postphlebitic syndrome


permanent damage to the venous valves of the leg
Severe→ skin ulceration, especially in the medial
malleolus of the leg.
About half of patients with pelvic vein thrombosis
or proximal leg DVT develop PE, which is
usually asymptomatic.
Diagnosis-Wells score for DVT
Diagnosis
compression ultrasonography

the noninvasive approach of choice for the diagnosis
of symptomatic patients with a first episode of
suspected DVT
A D-dimer assay is a useful "rule out" test

Levels increase in with MI, pneumonia, sepsis, cancer,
the post-op state, and 2nd/3rd trimester of pregnancy
venography

used only when noninvasive testing is not clinically
feasible or the results are equivocal
Modified Wells score for PE
Screen for malignancy
Malignancy screen: rectal examination,
stool testing for occult blood, pelvic
examination
recurrent thrombosis in spite of therapeutic
anticoagulation with oral anticoagulants is
more frequent in patients with VTE in
association with an occult neoplasm or
recurrent cancer.
Screen for hypercoagulable state
test for inherited thrombophilia





Initial thrombosis<50 without an immediately identified risk factor
A family history of venous thromboembolism
Recurrent venous thrombosis
Thrombosis occurring in unusual vascular beds such as portal,
hepatic, mesenteric, or cerebral veins
A history of warfarin-induced skin necrosis, which suggests
protein C deficiency
Clinical value?


the strongest risk factor for VTE recurrence is the prior VTE
event itself, particularly if idiopathic
anticoagulant prophylaxis is rarely recommended in
asymptomatic affected family members outside of high risk
situations.
Treatment
Anticoagulant therapy is indicated for
patients with symptomatic proximal DVT
pulmonary embolism occur in
approximately ½ of untreated individuals,
most often within days or weeks of the
event.
Initial treatment: start acutely



unfractionated heparin (prolong aPTT to 1.5 to 2.5
times aPTTc), low molecular weight heparin, or
fondaparinux
continued for at least five days
oral anticoagulation overlapped with one of these
agents for at least five days.
initiated simultaneously with the LMWH or fondaparinux. with
UFH a therapeutic aPTT must first be documented
at an initial oral dose of 5 mg/day
warfarin should prolong the INR to a target of 2.5

heparin product can be discontinued on day five or six
if the INR has been therapeutic for two consecutive
days
stopped if a precipitous or sustained fall in the platelet count,
or a platelet count <100,000/mL

thrombolytic agents or thrombectomy
hemodynamically unstable pulmonary embolus or massive
iliofemoral thrombosis and a low bleeding risk

Inferior vena caval filter placement
contraindication or complication of anticoagulant therapy in
an individual with, or at high risk for, proximal vein thrombosis
or PE.
Treatment duration


first DVT due to a reversible or time-limited risk factor
and those with a first unprovoked episode of DISTAL
DVT : treated for at least three months.
Indefinite therapy might be preferred in patients with
a first unprovoked episode of PROXIMAL DVT who have a
greater concern about recurrent VTE and a relatively lower
concern about the risks and burdens of long-term
anticoagulant therapy > 6 months.
ACCP guidelines recommend a target INR between 2.0 and
3.0
early ambulation is advised
use of an elastic compression stocking
has been recommended to prevent the
postphlebitic syndrome
The end