Case presentation

1
Case presentation

• 98.5.6

2
Patient profile

• Name?X?
• 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 TUIPPPS 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 historydenied

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
• BP130/75mmHg, PR78bpm, RR18pm, BT36.6 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

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• 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
  circumference52.4cm) 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
Urine routine Urine routine
Glucose -
Bilirubin -
Ketone /-
SG 1.01
OB -
pH 6.0
Protein 30
Urobilinogen 1.0
Nitrite
Leukocyte 1
RBC 0-2
WBC 2-5
Epi 0-2
Crystal -
cast -
biochemistry biochemistry
GOT 17
GPT 14
BUN 10.4
Crea 1.53
CK 52
Glu 130
UA 5.9
Na 139
K 3.1
Cl 102
CRP 5.4
CBC/DC CBC/DC Baso 0.5
WBC 12.37 Mono 5.4
RBC 6.32 Lymph 21.4
Hgb 17.2 PT 9.9
Hct 51.5 PTc 10.7
MCV 81.5 INR 1.0
PLT 214 PTT 20.9
Neut 72.2 PTTc 28.9
eosin 0.5 D-Dimer 879
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Impression

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

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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

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5/1 CXR
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PTT follow up
5/1 5/2 5/3 5/4
1348 2314 0710 1200 1845 0700 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
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• 5/4
• cardiac echo
• Adequate LV systolic function but impaired
  diastolic function
• Mild TR with pulmonary hypertension and estimated
  RVSP33.55 mmHg
• AV sclerosis
• Add coumadin 0.5 QD/AMPC
• 5/5
• CTA

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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

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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

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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.

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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 

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• 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

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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.

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Screen for hypercoagulable state

• test for inherited thrombophilia
• Initial thrombosislt50 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.

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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.

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• 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

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• 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 lt100,000/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.

35

• 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 gt 6
  months.
• ACCP guidelines recommend a target INR between
  2.0 and 3.0

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

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The end