A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg

trimurtulu · #1 12-13-2008, 07:06 AM

Clinical Case

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

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Question 1

What test(s) might be helpful in the evaluation of the patient?

Quote:

a) Duplex ultrasound
b) Venography
c) D-Dimer
d) Complete blood count

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #2 12-13-2008, 07:13 AM

Clinical Case: Question 2

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

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Question 2

A doppler ultrasound of his right leg is performed. It reveals a DVT that extends from his upper calf to his mid-thigh. There are no other abnormalities noted.

Select an appropriate treatment option:

Quote:

a) a) Admit and use intravenous unfractionated heparin
b) Admit and use subcutaneous unfractionated heparin
c) Admit and use intravenous low molecular weight heparin (LMWH)
d) Discharge on subcutaneous low molecular weight heparin (LMWH)
e) Discharge on subcutaneous unfractionated heparin

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #3 12-13-2008, 07:19 AM

Clinical Case: Question 3

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

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Question 3

You decide that the patient is a good candidate for outpatient therapy. You call his primary care provider (PCP) to make the arrangements. The primary care provider is not very familiar with low molecular weight heparins and he asks you the following questions:

What is the mechanism of action of low molecular weight heparins?

Quote:

a) Acts like a fibrinolytic
b) Replaces Factor VIII and von Willebrand Factor
c) Prevents platelet aggregation
d) Indirectly inhibits thrombin

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #4 12-13-2008, 07:24 AM

Clinical Case: Question 4

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

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Question 4

What is a contraindication to the use of low molecular weight heparins?

Quote:

a) History of Heparin Induced Thrombocytopenia (HIT)
b) Platelet count of 110,000 mm3
c) History of abdominal surgery two months ago
d) Patient has been already taking warfarin sodium

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #5 12-13-2008, 05:20 PM

Clinical Case: Question 5

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

-------------------

Question 5

The PCP said he had heard that the FDA looks upon each LMWH as a unique drug with many unique properties. Is there any aspect in which the LMWHs are clearly similar?

Quote:

a) Efficacy
b) Molecular weight
c) Pharmacokinetics
d) Production by fractionation of unfractionated heparin

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #6 12-13-2008, 05:23 PM

Clinical Case: Question 6

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

-------------------

Question 6

What laboratory monitoring, specific for the effects of low molecular weight heparin therapy, should be done?

Quote:

a) Activated partial thromboplastin time
b) Antithrombin activity
c) INR
d) Platelet count

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #7 12-13-2008, 05:26 PM

Clinical Case: Question 7

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

-------------------

Question 7

The PCP is curious whether any special tests exist that can be used to evaluate the effect of a LMWH. You tell him that anti-Xa activity can be used as an indirect measure of effect; however, it does not need to be used in most patients. He then asks which patient populations should be monitored for anti-Xa activity?

Quote:

a) Cirrhotics
b) Currently taking aspirin
c) Have had prior gastric stapling procedure
d) Renal Insufficiency

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #8 12-13-2008, 05:29 PM

Clinical Case: Question 8

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

-------------------

Question 8

The PCP now feels better about LMWHs and is ready to use them; however he has some questions about outpatient management and about the specific LMWH agents. He wants to know if any of the low molecular weight heparins has an indication from the FDA for outpatient management of deep venous thrombosis?

Quote:

a) Dalteparin
b) Enoxaparin
c) Tinzaparin
d) Nadroparin
e) More than one of the above

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #9 12-13-2008, 05:31 PM

Clinical Case: Question 9

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

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Question 9

You recommend that the patient be treated with enoxaparin (Lovenox®). The PCP asks if you could substitute a different low molecular weight heparin for the enoxaparin?

Quote:

a) No; therapeutic interchange of LMWH products is not advisable.
b) Yes; use dalteparin
c) Yes; use tinzaparin
d) Yes; use hirudin

This question has more than one answer that could be correct.

Answer & Explanation

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trimurtulu · #10 12-13-2008, 05:34 PM

Clinical Case: Question 10

History of Present Illness

Quote:

A 43 year old man presents to the emergency department complaining of a mildly swollen, painful leg for the past four days. He has felt well otherwise and has no fever, nausea, vomiting, shortness of breath, or chest pain. He denies any history of cancer, clotting disorders, trauma to the extremity, or previous thromboembolic disease. He has been commuting frequently to a neighboring city on business for the last two weeks. He has no significant past medical history and takes no medications. He is a ten-pack-year smoker but denies the use of drugs or alcohol. He lives locally with his family and has been with the same job for 15 years.

Physical exam

Quote:

Physical exam reveals a well-developed and well-nourished male in no distress. He is experiencing mild pain. Vital signs are blood pressure 132/81, pulse 84, respirations 22, and temperature 37°C (98.6°F). Pulse oximetry reveals a room air oxygen saturation of 97%. His neck exam reveals no jugular venous distention and no bruits. Heart sounds are normal without murmur, gallop, or rub. Respirations are unlabored and without rales, wheezes or rhonchi. His abdominal exam is benign. His pulses are full and symmetric. His right calf is swollen three centimeters larger than his left, has very minimal erythema and is not warm, and is tender to palpation. No cords are palpable, but Homan's sign is positive.

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Question 10

The patient has been discharged with follow-up care established with the PCP. Assume that you are now the PCP. The following questions/situations arise relative to your patient.

You are contacted by the laboratory because the patient had a complete blood count on the third day of therapy that revealed the platelet count to be 115,000 platelets/mm3 (versus 210,000 platelets/mm3 when he was originally diagnosed). You know the patient is feeling well because you had just talked to him on the telephone. You should:

Quote:

a) Continue therapy
b) Continue therapy and transfuse a six-pack of platelets
c) Stop the low molecular weight heparin and use protamine sulfate
d) Stop the low molecular weight heparin and use standard heparin

This question has more than one answer that could be correct.

Answer & Explanation

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