Professional Documents
Culture Documents
from Deep Within ……… Level II
Learning Objectives
After completing this case study, the reader should be able to:
Define acute deep vein thrombosis (DVT), and discuss its pathophysiology.
Discuss the clinical presentation of patients with a DVT.
Develop a pharmacotherapeutic care plan for the management of a patient with a DVT.
Educate a patient receiving anticoagulation therapy for the treatment of a DVT.
Patient Presentation
Chief Complaint
“I’m having pain in my leg.”
HPI
Rodney Cross is a 48yearold man who presents to his primary care physician because of pain in his right leg. He states that he awoke with the pain 3
days ago and that it has been continuous, although it hurts more when he walks. The pain is located behind his right knee and extends down into his
calf. He rates the pain intensity as 3/10 at this time. The patient denies CP and SOB. He denies recent travel, immobility, and leg injury. The patient did
start pravastatin 40 mg daily for treatment of dyslipidemia approximately 3 months prior to this visit. He stopped the pravastatin 3 days ago because he
thought it might be causing his leg pain, but the pain has continued.
PMH
Hypertension
Dyslipidemia
Graves’ disease with thyroid ablation
Gout
Left ankle fracture 9 years ago that required a cast but no surgery
Remote history of depression
PSH
Left herniorrhaphy about 10 years ago. Pilonidal cyst excision in remote past.
FH
Father died at age 81 of liver failure. Mother, one brother, and son all alive and well. No family history of venous thromboembolism or clotting disorders.
SH
Married, one adult child. Drinks one to two alcoholic beverages daily. Smokes one cigar per month, no cigarettes. Denies illicit drug use.
Meds
Allopurinol 300 mg po once daily
Hydrochlorothiazide 12.5 mg once daily
Lisinopril 10 mg once daily
Levothyroxine 150 mcg po once daily
Pravastatin 40 mg po once daily (discontinued 3 days ago)
All
NKDA
ROS
Constitutional: No chills, no fatigue.
Eyes: No eye pain or changes in vision.
ENT: No sore throat.
Skin: No pigmentation changes, no nail changes.
Cardiovascular: No CP, palpitations, or syncope.
Respiratory: No cough, SOB, wheezing, or stridor.
GI: No abdominal pain, nausea, diarrhea, or vomiting.
Musculoskeletal: No neck pain, back pain, or injury.
Neurologic: No dizziness, headache, or focal weakness.
Psychiatric/behavioral: Remote history of depression. Not a current problem.
Physical Examination
Gen
Somewhat overweight, Caucasian man who appears comfortable. Cooperative, A & O × 3, normal affect.
VS
BP 132/76, P 75 regular, R 16, T 98.3°F, O2 sat 97/RA; Wt 194 lb, Ht 6′0″
Skin
Warm, dry, normal color. No rash or induration.
HEENT
Pupils equal and reactive to light. EOM intact. Mucous membranes moist and pink.
Neck
Normal range of motion with no meningeal signs
Lungs/Thorax
Breath sounds normal, no respiratory distress
CV
RRR, no rubs, murmurs, or gallops
Abd
Nontender, no masses, no distension, no peritoneal signs
MS/Ext
Upper extremities: Normal by inspection, no CCE, normal ROM.
Lower extremities: Right calf tight, warm to touch, and tender with 1+ pretibial pitting edema. LLE without redness, warmth, and swelling. Lower extremity
pulses and sensation are normal bilaterally. Normal ROM.
Neuro
Glasgow coma scale of 15, no focal motor deficits, no focal sensory deficits
Labs
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Lower extremity venous duplex ultrasonography: “Acute DVT of right distal superficial femoral, popliteal, and peroneal veins. No compression or flow in
these vessels.”
(Note to reader: The “superficial femoral vein” is actually a deep vein, in spite of its name. Use of the name “femoral vein” is preferred because it is less
confusing. However, the name “superficial femoral vein” is still encountered, as it is in this patient’s venous duplex report.)
Assessment
Acute DVT in right distal femoral, popliteal, and peroneal veins
Clinical Pearl
Current evidence does not clearly establish the appropriate duration of anticoagulation therapy for many patients with DVTs. A decision must therefore
be based on a careful comparison of the benefits of continuing anticoagulation (primarily a decreased risk of DVT recurrence and potential sequelae)
versus the risk of adverse events (primarily bleeding) in each patient.