Case presentationCase presentation

98.5.698.5.6

Patient profilePatient profile

Name:Name: 邱邱 XX 四四Age: 64Age: 64

Gender: maleGender: male

Chart number: 02251392Chart number: 02251392

Admitted to our ward on 98.5.1Admitted to our ward on 98.5.1

Chief complaintChief complaint

Left lower limb swelling for about 2 days.Left lower limb swelling for about 2 days.

Present illnessPresent illness

This 64-year-old man lived in nursing home and has beeThis 64-year-old man lived in nursing home and has been a patient of gastric cancer s/p operation in MK95, old stn a patient of gastric cancer s/p operation in MK95, old stroke in MK93 with vertebral-basilar insufficiency, benign roke in MK93 with vertebral-basilar insufficiency, benign prostate hyperplasia, hypertension and depression. prostate hyperplasia, hypertension and depression. He got regular followed up in our Urology OPD to deal wiHe got regular followed up in our Urology OPD to deal with benign prostate hyperplasia. th benign prostate hyperplasia.

Besides, recent urinary tract infection episode was noted Besides, recent urinary tract infection episode was noted (urine culture: Providencia stuartii) due to decreased urin(urine culture: Providencia stuartii) due to decreased urine amount and under antibiotic treatment with cravit from e amount and under antibiotic treatment with cravit from our urology OPD since 4/27.our urology OPD since 4/27.

According to his family, he complained of unsteady gait 2 According to his family, he complained of unsteady gait 2 days ago and left lower limb swelling and firmness was ndays ago and left lower limb swelling and firmness was noted by family. Soreness and numbness were also told boted by family. Soreness and numbness were also told by patient. he denied pain or hot sensation. The color of ley patient. he denied pain or hot sensation. The color of left leg was slight purple.ft leg was slight purple.He denied similar episode before and recent lower limb trHe denied similar episode before and recent lower limb trauma. His daily activity was normal.auma. His daily activity was normal.There was no fever, chills, body weight change, orthopnThere was no fever, chills, body weight change, orthopnea, paroxysmal noctual dyspnea, shortness of breath, chea, paroxysmal noctual dyspnea, shortness of breath, chest pain, nausea, vomiting, abdominal pain or diarrhea. est pain, nausea, vomiting, abdominal pain or diarrhea. Cough with whitish sputum was noted for many years. Cough with whitish sputum was noted for many years.

Due to this problem, he took diuretics for 2 days but no oDue to this problem, he took diuretics for 2 days but no obvious effect. Then he was taken to our ER for help.bvious effect. Then he was taken to our ER for help.

In our ER, his consciousness was alert and oriented. On In our ER, his consciousness was alert and oriented. On physical examination, his vital sign was within normal limiphysical examination, his vital sign was within normal limit. Lab investigation showed elevated D-dimer level. t. Lab investigation showed elevated D-dimer level.

Deep venous thrombosis was suspected so he was admiDeep venous thrombosis was suspected so he was admitted to our ward for further management.tted to our ward for further management.

Past historyPast history

Gastric fundus GIST post OPGastric fundus GIST post OPOld stroke with chronic dizziness since MK93 Old stroke with chronic dizziness since MK93 Hypertension, stop drug for 2 years Hypertension, stop drug for 2 years History of peptic ulcer History of peptic ulcer History of reflux esophagitis History of reflux esophagitis Benign prostate hyperplasia Benign prostate hyperplasia DepressionDepressionOperation history:Operation history:

gastric fundus gastrointestinal stromal tumor post wedge resectigastric fundus gastrointestinal stromal tumor post wedge resection of gastric fundus tumor on 2006.11.8on of gastric fundus tumor on 2006.11.8

Gallbladder stone with acute cholecystitis post laparoscopic cholGallbladder stone with acute cholecystitis post laparoscopic cholecystectomy in MK91ecystectomy in MK91

BPH post TUIP+PPS in 2007/12BPH post TUIP+PPS in 2007/12

Personal historyPersonal history

Cigarette Smoking : 3-4PPD for about 20 yCigarette Smoking : 3-4PPD for about 20 years,quit for 6-7 yearsears,quit for 6-7 years

Alcohol : denied Alcohol : denied

Contact history : NilContact history : Nil

Travel history : NilTravel history : Nil

Allergy history:deniedAllergy history:denied

Current medicationCurrent medication Urology OPDUrology OPD

Sronin S.C. 1 Sronin S.C. 1 ＊ ＊ TID PCTID PC

Wecoli 1 Wecoli 1 ＊ ＊ TID PC TID PC

Harnalidge 1 Harnalidge 1 ＊ ＊ HS HS

Cravit 1 Cravit 1 ＊ ＊ QDAMPC QDAMPC

rasitol 1 rasitol 1 ＊ ＊ PRNPRN Psychi OPDPsychi OPD

Eurodin 1# hs, kinxetine 2# hs, stilnox 1# hsEurodin 1# hs, kinxetine 2# hs, stilnox 1# hs Neuro OPDNeuro OPD

Xanax 1# bidpc, dulcolax 2# hs, nobby 1# om, MgO 1# tidpc Xanax 1# bidpc, dulcolax 2# hs, nobby 1# om, MgO 1# tidpc

Family historyFamily history DM and hypertensionDM and hypertension Denied inherited thrombophiliaDenied inherited thrombophilia

Physical examinationPhysical examination

Conscious: Alert, E4V5M6Conscious: Alert, E4V5M6Vital signVital sign

BP:130/75mmHg, PR:78bpm, RR:18pm, BT:36.6 degreeBP:130/75mmHg, PR:78bpm, RR:18pm, BT:36.6 degree

HEENTHEENT Conjunctiva: not pale, sclera: not ictericConjunctiva: not pale, sclera: not icteric

NeckNeck supple, lymphadenopathy(-) jugular vein engorgement(-)supple, lymphadenopathy(-) jugular vein engorgement(-)

Chest: symmetric expansionChest: symmetric expansion breathing sound: Clearbreathing sound: Clear heart sound: regular, normal S1/S2, no S3/S4 heart sound: regular, normal S1/S2, no S3/S4

AbdomenAbdomen Soft & flat, Bowel sounds: normoactiveSoft & flat, Bowel sounds: normoactive Muscle guarding(-), tenderness(-), rebounding pain(-)Muscle guarding(-), tenderness(-), rebounding pain(-) Liver/spleen: impalpableLiver/spleen: impalpable CV angle knocking pain: (-/-) CV angle knocking pain: (-/-)

Lower limbsLower limbs left lower limb swelling (thigh circumference=52.4cm) and mild rleft lower limb swelling (thigh circumference=52.4cm) and mild r

ed-purple colored, but no pain, tenderness and local heat, no sued-purple colored, but no pain, tenderness and local heat, no superficial vein distensionperficial vein distension

Pre-tibial pitting edema in left legPre-tibial pitting edema in left leg

Skin Skin petechiae/hematoma(-), bedsore/wound(-), skin rash(-)petechiae/hematoma(-), bedsore/wound(-), skin rash(-)

Lab dataLab data

CBC/DCCBC/DC BasoBaso 0.50.5

WBCWBC 12.3712.37 MonoMono 5.45.4

RBCRBC 6.326.32 LymphLymph 21.421.4

HgbHgb 17.217.2 PTPT 9.99.9

HctHct 51.551.5 PTcPTc 10.710.7

MCVMCV 81.581.5 INRINR 1.01.0

PLTPLT 214214 PTTPTT 20.920.9

NeutNeut 72.272.2 PTTcPTTc 28.928.9

eosineosin 0.50.5 D-DimerD-Dimer 879879

biochemistrybiochemistry

GOTGOT 1717

GPTGPT 1414

BUNBUN 10.410.4

CreaCrea 1.531.53

CKCK 5252

GluGlu 130130

UAUA 5.95.9

NaNa 139139

KK 3.13.1

ClCl 102102

CRPCRP 5.45.4

Urine routineUrine routine

GlucoseGlucose --

BilirubinBilirubin --

KetoneKetone +/-+/-

SGSG 1.011.01

OBOB --

pHpH 6.06.0

ProteinProtein 3030

UrobilinogenUrobilinogen 1.01.0

NitriteNitrite ++

LeukocyteLeukocyte 1+1+

RBCRBC 0-20-2

WBCWBC 2-52-5

EpiEpi 0-20-2

CrystalCrystal --

castcast --

Impression Impression

Left lower limb deep venous thrombosisLeft lower limb deep venous thrombosis

Urinary tract infection, improvedUrinary tract infection, improved

Gastric cancer s/p operationGastric cancer s/p operation

HypertensionHypertension

Benign prostate hyperplasiaBenign prostate hyperplasia

Plan Plan

Heparin 5000U IV bolus, then 20000U + Heparin 5000U IV bolus, then 20000U + N/S 500ml keep pump 20ml/hrN/S 500ml keep pump 20ml/hr

Follow up PTTFollow up PTT

Arrange cardiac echo and CTA of bilateral Arrange cardiac echo and CTA of bilateral lower limbslower limbs

Check protein C, protein S, lupus Check protein C, protein S, lupus anticoagulantanticoagulant

5/1 CXR5/1 CXR

PTT follow upPTT follow up

5/15/1 5/25/2 5/35/3 5/45/4

13481348 23142314 07100710 12001200 18451845 07000700 13001300 18301830 00000000 08000800

PTPT 9.99.9 9.99.9

PTcPTc 10.710.7 10.510.5

INRINR 1.01.0 1.01.0

PTTPTT 20.920.9 41.141.1 42.142.1 39.039.0 40.740.7 49.949.9 37.337.3 36.936.9 40.440.4 52.852.8

PTTcPTTc 28.928.9 28.928.9 28.928.9 28.728.7 28,728,7 28.728.7 29.029.0 29.029.0 29.029.0 28.328.3

5/4 5/4 cardiac echocardiac echo

Adequate LV systolic function but impaired diastolic function Adequate LV systolic function but impaired diastolic function

Mild TR with pulmonary hypertension and estimated RVSP:3Mild TR with pulmonary hypertension and estimated RVSP:33.55 mmHg 3.55 mmHg

AV sclerosisAV sclerosis Add coumadin 0.5# QD/AMPCAdd coumadin 0.5# QD/AMPC

5/55/5 CTACTA

Deep venous thrombosisDeep venous thrombosis

Approximately 2/3 of symptomatic VTE evApproximately 2/3 of symptomatic VTE events are hospital acquired ents are hospital acquired Residents of skilled nursing facilities are espeResidents of skilled nursing facilities are espe

cially vulnerablecially vulnerable DVT occurs about 3 times more often than PEDVT occurs about 3 times more often than PE

Risk factorRisk factorHistory of immobilization or History of immobilization or prolonged hospitalization/bed prolonged hospitalization/bed rest rest Recent surgery Recent surgery Obesity Obesity cigarette smokingcigarette smokingPrior episode of VTEPrior episode of VTELower extremity trauma Lower extremity trauma Malignancy Malignancy Use of OCP or HRT Use of OCP or HRT Pregnancy or postpartum Pregnancy or postpartum status status

StrokeStroke COPDCOPD

Clinical manifestation Clinical manifestation

Classic symptoms of DVT include swelling, pain, Classic symptoms of DVT include swelling, pain, and discoloration in the involved extremity and discoloration in the involved extremity not necessarily a correlation between the location of snot necessarily a correlation between the location of s

ymptoms and the site of thrombosis.ymptoms and the site of thrombosis.

Physical examination Physical examination a palpable cord (reflecting a thrombosed vein), calf paa palpable cord (reflecting a thrombosed vein), calf pa

in, ipsilateral edema or swelling with a difference in cain, ipsilateral edema or swelling with a difference in calf diameters, warmth, tenderness, erythema, and/or slf diameters, warmth, tenderness, erythema, and/or superficial venous dilation. uperficial venous dilation.

differential diagnosis differential diagnosis

CellulitisCellulitisSuperficial vein phlebitis Superficial vein phlebitis Chronic venous insufficiency : the most common Chronic venous insufficiency : the most common cause of chronic unilateral leg edema cause of chronic unilateral leg edema Lymphedema Lymphedema Popliteal (Baker's) cyst : Sudden, severe calf disPopliteal (Baker's) cyst : Sudden, severe calf discomfort comfort Knee abnormality Knee abnormality Drug-induced edema  Drug-induced edema  Calf muscle pull or tear  Calf muscle pull or tear 

The major adverse outcome of DVT: The major adverse outcome of DVT: postphlebitpostphlebitic syndromeic syndrome permanent damage to the venous valves of the legpermanent damage to the venous valves of the leg Severe→ skin ulceration, especially in the medial mallSevere→ skin ulceration, especially in the medial mall

eolus of the leg.eolus of the leg.

About half of patients with pelvic vein thrombosis About half of patients with pelvic vein thrombosis or proximal leg DVT develop PE, which is usuallor proximal leg DVT develop PE, which is usually asymptomaticy asymptomatic. .

Diagnosis-Wells score for DVTDiagnosis-Wells score for DVT

Diagnosis Diagnosis

compression ultrasonography compression ultrasonography the noninvasive approach of choice for the diagnosis the noninvasive approach of choice for the diagnosis

of symptomatic patients with a first episode of suspectof symptomatic patients with a first episode of suspected DVT ed DVT

A D-dimer assay is a useful "rule out" test A D-dimer assay is a useful "rule out" test Levels increase in with MI, pneumonia, sepsis, cancer,Levels increase in with MI, pneumonia, sepsis, cancer,

the post-op state, and 2 the post-op state, and 2ndnd/3rd trimester of pregnancy/3rd trimester of pregnancy

venography venography used only when noninvasive testing is not clinically feused only when noninvasive testing is not clinically fe

asible or the results are equivocalasible or the results are equivocal

Modified Wells score for PEModified Wells score for PE

Screen for malignancyScreen for malignancy

Malignancy screen: rectal examination, Malignancy screen: rectal examination, stool testing for occult blood, pelvic stool testing for occult blood, pelvic examinationexamination

recurrent thrombosis in spite of therapeutic recurrent thrombosis in spite of therapeutic anticoagulation with oral anticoagulants is anticoagulation with oral anticoagulants is more frequent in patients with VTE in more frequent in patients with VTE in association with an occult neoplasm or association with an occult neoplasm or recurrent cancer.recurrent cancer.

Screen for hypercoagulable stateScreen for hypercoagulable state

test for inherited thrombophilia test for inherited thrombophilia Initial thrombosis<50 without an immediately identified risk factor Initial thrombosis<50 without an immediately identified risk factor A family history of venous thromboembolism A family history of venous thromboembolism Recurrent venous thrombosis Recurrent venous thrombosis Thrombosis occurring in unusual vascular beds such as portal, hThrombosis occurring in unusual vascular beds such as portal, h

epatic, mesenteric, or cerebral veins epatic, mesenteric, or cerebral veins A history of warfarin-induced skin necrosis, which suggests protA history of warfarin-induced skin necrosis, which suggests prot

ein C deficiencyein C deficiency

Clinical value?Clinical value? the strongest risk factor for VTE recurrence is the prior VTE evethe strongest risk factor for VTE recurrence is the prior VTE eve

nt itself, particularly if idiopathicnt itself, particularly if idiopathic anticoagulant prophylaxis is rarely recommended in asymptomatanticoagulant prophylaxis is rarely recommended in asymptomat

ic affected family members outside of high risk situations. ic affected family members outside of high risk situations.

Treatment Treatment

Anticoagulant therapy is indicated for Anticoagulant therapy is indicated for patients with symptomatic proximal DVT patients with symptomatic proximal DVT

pulmonary embolism occur in pulmonary embolism occur in approximately ½ of untreated individuals, approximately ½ of untreated individuals, most often within days or weeks of the most often within days or weeks of the event. event.

Initial treatment: start acutelyInitial treatment: start acutely unfractionated heparin (prolong aPTT to 1.5 to 2.5 timunfractionated heparin (prolong aPTT to 1.5 to 2.5 tim

es aPTTc), low molecular weight heparin, or fondaparies aPTTc), low molecular weight heparin, or fondaparinux nux

continued for at least five dayscontinued for at least five days oral anticoagulation overlapped with one of these ageoral anticoagulation overlapped with one of these age

nts for at least five days. nts for at least five days. initiated simultaneously with the LMWH or fondaparinux. with initiated simultaneously with the LMWH or fondaparinux. with UFH a therapeutic aPTT must first be documented UFH a therapeutic aPTT must first be documented

at an initial oral dose of 5 mg/dayat an initial oral dose of 5 mg/day

warfarin should prolong the INR to a target of 2.5 warfarin should prolong the INR to a target of 2.5

heparin product can be discontinued on day five or six heparin product can be discontinued on day five or six if the INR has been therapeutic for two consecutive dif the INR has been therapeutic for two consecutive daysays

stopped if a precipitous or sustained fall in the platelet count, stopped if a precipitous or sustained fall in the platelet count, or a platelet count <100,000/mL or a platelet count <100,000/mL

thrombolytic agents or thrombectomy thrombolytic agents or thrombectomy hemodynamically unstable pulmonary embolus or massive ilihemodynamically unstable pulmonary embolus or massive iliofemoral thrombosis and a low bleeding risk ofemoral thrombosis and a low bleeding risk

Inferior vena caval filter placement Inferior vena caval filter placement contraindication or complication of anticoagulant therapy in acontraindication or complication of anticoagulant therapy in an individual with, or at high risk for, proximal vein thrombosis n individual with, or at high risk for, proximal vein thrombosis or PE. or PE.

Treatment durationTreatment duration first DVT due to a reversible or time-limited risk factor first DVT due to a reversible or time-limited risk factor

and those with a first unprovoked episode of DISTAL and those with a first unprovoked episode of DISTAL DVT : treated for at least three months. DVT : treated for at least three months.

Indefinite therapy might be preferred in patients with Indefinite therapy might be preferred in patients with a first unprovoked episode of PROXIMAL DVT who have a a first unprovoked episode of PROXIMAL DVT who have a greater concern about recurrent VTE and a relatively lower greater concern about recurrent VTE and a relatively lower concern about the risks and burdens of long-term concern about the risks and burdens of long-term anticoagulant therapy > 6 months. anticoagulant therapy > 6 months.

ACCP guidelines recommend a target INR between 2.0 and ACCP guidelines recommend a target INR between 2.0 and 3.0 3.0

early ambulation is advised early ambulation is advised

use of an elastic compression stocking hause of an elastic compression stocking has been recommended to prevent the postps been recommended to prevent the postphlebitic syndromehlebitic syndrome

The endThe end