Cardiac Journal on Deep Vein Thrombosis
Case Description
This case involves a 45-year-old Asian female who presented at the cardiologist office for review. She complained of swelling on the left leg for 2 weeks. She uses combined oral contraceptives for birth control for the past 3 years. She has a history of traveling to South Africa, which she admits was a long flight. She has no history of trauma. On examination, her left lower limb appeared dusky and had generalized swelling of the leg. It was also warm to touch. Her peripheral pulses were palpable. She also reported the pain of the lower limb for the past 10 days. Her vitals were: BP 115/65 mmHg, pulse 76 beats/minute, respiration 20 breaths /minute, and the temperature at 98.4oF. The S1 and S2 heard and normal.
Diagnostic investigations
Platelet 80,000
WBC TC 4000
HB 9.4
ESR 36 mm
PT control 12/15 seconds
APTT control 26
INR 1.1
RBS 141 GMS/DL
Urea – 43
Creatinine – 1.1
12 Lead EKG – sinus tachycardia with poor prognosis of the R wave
Chest x-ray- cardiomegaly, pleural effusion.
Differential diagnosis
- Cellulitis- presents with erythema, redness, pain swelling, and warmth at the site of skin infection. It is an infection caused by a pathogen. In severe cases, it can cause fevers and chills in the patient (Patel, 2019).
- Septic thrombophlebitis is characterized by venous thrombosis, with bacteremia or fungal infection. It can affect both superficial or deep veins. It presents with fever, tachycardia, and bacteremia (Patel, 2019). The patient in this case study does not have tachycardia fever or bacteremia.
- Deep vein thrombosis (DVT): It presents with edema, leg pain, tenderness, and warmth or erythema at the site of vein thrombosis (Patel, 2019).
A Doppler ultrasound was done on the left leg, which showed thrombosis of the left popliteal vein, which extended to the superficial femoral vein.
CT Pulmonary angiogram- no pulmonary embolism.
Impact of demographics on management
Women in the childbearing years are at higher risk of developing DVT due to the use of hormonal contraceptives, infertility treatments, and pregnancies. Both sexes are at risk of developing DVT is a result of major trauma, major surgery, or long periods of immobility. Treatment and lifestyle modification are similar in both sexes. In women using contraceptives or infertility treatments, it must be taken into consideration (Langford, 2019). During pregnancy and postpartum, a woman is at higher risk of developing DVT and Pulmonary Embolism. Warfarin is teratogenic, therefore in pregnancy, the low molecular weight heparin is preferred. Anticoagulation therapy should be given for 3 months and continued for at least 6 weeks into the postpartum period (Wilbur & Shian, 2017).
Management of the patient
The treatment approaches are aimed at preventing pulmonary embolism and reduce morbidity. The patient can be treated as an outpatient with regular follow up (Patel, 2019).
The
patient was started on low molecular weight heparin and warfarin. The patient was given subcutaneous low molecular weight for the first 5 days until the INR was at 1.9. She was then started on 10 mg of warfarin daily for the first 2 days with close monitoring of the INR. The INR was maintained at a therapeutic range of 2.0 -2.5.
She was advised to stop the oral contraceptives and was encouraged to consider using a non-hormonal method of birth control.
She also required the use of compression stockings on the left leg to improve blood flow, reduce the swelling and pain.
The patient was under close follow up with the clinical visits scheduled at one month, three months, and six months intervals. The INR is essential as it shows if the treatment is effective. The patient is also assessed for any signs of complications, especially pulmonary embolism.
References
Langford, A. (2019, October 3). Search Highlights Gender Differences for Deep Vein Thrombosis | Everyday Health. Retrieved from EverydayHealth.com website: https://www.everydayhealth.com/news/truth-about-sex-differences-deep-vein-thrombosis/
Patel, K. (2019, August 26). Deep Venous Thrombosis (DVT) Treatment & Management: Approach Considerations, General Principles of Anticoagulation, Heparin Use in Deep Venous Thrombosis. Retrieved from Medscape.com website: https://emedicine.medscape.com/article/1911303-treatment
Wilbur, J., & Shian, B. (2017). Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy. Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy, 95(5). Retrieved from https://www.aafp.org/afp/2017/0301/p295.pdf