DVT FM Presentation

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    History

    CC: Pt. is a 53-year-old male with a chief complaintof swelling and pain in his left lower extremity."

    PMH:

    y!e dia#etes$ hy!ertension$ andhy!erli!idemia$ o#esity.

    Social Hx: %oes not drin& al'ohol$ #ut does smoke1.5 packs of cigarettes daily( unmarried$ and li)es

    in !u#li' housing with his three 'hildren and onegrand'hild.

    ROS:*o +e)er or 'hills$ no 'hest !ain$ no shortness o+#reath$ and no swelling o+ the right leg.

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    hen you as& the !t what#rings him in: $ "t/s my le+tleg. he !ast +our days it has#een red$ swelling$ and !ain+ul-- and it seems to #e gettingworse."$ "t #egan se)eraldays ago$ and the swellingseems to #e getting worse. t

    hurts all the time( it doesn/te)en get #etter when restit. t seems to get a little worsewhen mo)e around. t hurtsto wal& as soon as try to

    stand on it."

    n His words0

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    "%id you do anything to injure your +oot1"

    He re!lies$ " do not remem#er any injury$ #ut there has #een thissore on the #ottom o+ my +oot +or se)eral months. here/s nothing

    draining out o+ the sore and it doesn/t hurt$ although my +oot doesn/tha)e mu'h +eeling in it."

    "Be+ore this ha!!ened$ where you were sitting down +or a long time without getting u! and using your legs$ su'h as ta&ing a long air!lane tri!( or ha)e you #een on #ed rest1"

    " wish 'ould go somewhere on an air!lane and get a good )a'ation$#ut 'an/t a2ord anything li&e that. ha)en/t #een on #ed rest oranything li&e that. /)e #een !retty #usy lately.""hen was the last time you were in the o'e1"

    "t has #een a long time now #e'ause my daughter and new #a#yre'ently mo)ed in with me and ha)e #een trying to ta&e 'are o+ the#a#y as well as &ee! my jo# as a #us dri)er$" he e4!lains.

    "Ha)e you #een ta&ing your medi'ation1"

    He re!lies$ " ha)e #een out o+ my medi'ation +or se)eral wee&s now."

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    Physi'al 4am

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    Summary andDiferentials

    6r. Smith is a 53-year-old man with o#esity$ ty!e dia#etes$ hy!ertension$ hy!erli!idemia$ and to#a''ouse who !resents with a +our day history o+ le+t lower

    e4tremity edema. He denies +e)er$ 'hest !ain$dys!nea$ &nown malignan'y$ trauma$ or !eriod o+ina'ti)ity.here is an ul'er on the !lantar sur+a'e o+his le+t +oot and edema and erythema in)ol)ing theentire le+t leg.

    Diferentials: Cellulitis, DVT Best diagnostic test to diferentiate: Venous

    Doppler.

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    Cellulitis

    Acute Inammation characterized by erythema,swelling, heat, pain.

    iabetics are more susceptible since diabeticneuropathy causes insensiti!ity to abnormalpressure distribution, ill"#tting shoes, cuts orpunctures which then de!elop into ulcers.

    $ack of fe!er does not r%o cellulitis but apresence of fe!er would support it.

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    %

    Acute swelling, pain, discoloration in thea&ected extremity.

    'ts. usually complain of a dull ache in the legthat worsens with prolonged standing andresol!es w% leg ele!ation.

    (omans )ign* 'ain of passi!e dorsiexion of

    the foot.

    +dema, tenderness, warmth

    isk factors* smoking, obesity, diabetes,

    sedentary lifestyle, (-, hyperlipidemia,increasin a e sur er rolon ed immobilit

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    Studies

    oppler ultrasound o+ the lower e4tremity 'on8rms withgood sensiti)ity and s!e'i8'ity i+ % is !resent. t has the #est

    !redi'ti)e )alue +or a %. Howe)er$ it 'an #e o)er- used$ whi'h'auses signi8'ant e4!ense.

    "dimer is a small !rotein +ragment !resent in the #lood a+tera #lood 'lot is degraded #y 8#rinolysis.

    o 9elati)ely sensiti)e$ #ut !oorly s!e'i8' test +or the !resen'e o+ %

    o *egati)e result low %-dimer 'on'entration in the #lood; !ra'ti'allyrules out throm#osis

    o Positi)e result may indi'ate throm#osis$ #ut does not rule out other!otential 'auses.

    o %-dimer is use+ul in e4'luding throm#oem#oli' disease when the!ro#a#ility is low.

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    % thera!y

    2oals of therapy for 3-

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    Prolonged Pro!hyla4is

    7arfarin *ot suita#le +or initial thera!y in throm#oem#olism #e'ause their onset

    o+ a'tion is too slow. 9ole is in maintaining anti'oagulant !rote'tion +or !rolonged !eriods.

    6onitor war+arin dose #y measuring the *9 and titrate the war+arindose e)ery three to se)en days to an *9 o+ [email protected]@.

    0actor :a inhibitors %oes not re>uire wee&ly la# monitoring o+ *9 and there+ore ma&es

    adheren'e an easier !ro'ess.

    Aonda!arinu4 is the !arental +orm o+ the drug and 'ould #e used insteado+ =6H.

    9i)aro4a#an is an oral +a'tor a inhi#itor and might #e used in !la'e o+war+arin.

    lthough these drugs ha)e #een +ound to #e generally as sa+e ande2e'ti)e as war+arin and =6H$ the negati)es o+ this 'lass o+

    medi'ations in'ludes high 'ost and di'ulty in re)ersing theanti'oa ulation in the +a'e o+ a #leed.

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    6ore than D5E o+ !ulmonary em#oli arise +rom throm#i in

    the dee! )enous system o+ the lower e4tremities. *inety

    !er'ent o+ deaths due to !ulmonary em#olism result withinan hour or two -- #e+ore diagnosti' and thera!euti' !lans

    'an #e im!lemented. here+ore$ !re)ention and !rom!t

    treatment o+ % is the most e2e'ti)e a!!roa'h to

    !re)ention o+$ and death due to em#olism.

    -rt as outpatient if*

    Hemodynamically stable

    Good kidney unction

    !o" risk or bleeding

    Stable and supporti#e $ome en#ironment

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    %ia#eti' Aoot 4am

    F+ten in dia#eti's$ +oot ul'eration is the result o+ impairedsensationdistal symmetri' !olyneuro!athy; and impairedperfusiondia#etes )as'ulo!athy and !eri!heral arterial disease;.

    )ensory testing$ a''ording to the meri'an %ia#etes sso'iation %;$'an #e 'ondu'ted with a