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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.

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Case presentation

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  1. Case presentation 98.5.6

  2. Patient profile • Name:邱X四 • Age: 64 • Gender: male • Chart number: 02251392 • Admitted to our ward on 98.5.1

  3. Chief complaint • Left lower limb swelling for about 2 days.

  4. 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.

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. 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

  10. Family history • DM and hypertension • Denied inherited thrombophilia

  11. 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

  12. 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(-)

  13. Lab data

  14. Impression • Left lower limb deep venous thrombosis • Urinary tract infection, improved • Gastric cancer s/p operation • Hypertension • Benign prostate hyperplasia

  15. 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

  16. 5/1 CXR

  17. PTT follow up

  18. 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

  19. Deep venous thrombosis

  20. 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

  21. 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

  22. 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.

  23. 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 

  24. 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.

  25. Diagnosis-Wells score for DVT

  26. Diagnosis

  27. 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

  28. Modified Wells score for PE

  29. 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.

  30. 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.

  31. 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.

  32. 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

  33. 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.

  34. 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

  35. early ambulation is advised • use of an elastic compression stocking has been recommended to prevent the postphlebitic syndrome

  36. The end

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