07 - 53 yo M with leg swelling

Question 1

what is the single largest risk factor for CV mortality in the US?

Answer 1

HTN

Question 2

what is the half life of warfarin? how long does it take to reach steady state (stable)?

Answer 2

• 40 hours

- 5-7 days

Question 3

what is the wagner grading system for ulcer classification?

Answer 3

grade 1: diabetic ulcer
grade 2: ulcer extension (involving ligament, tendon, joint capsule, fascia)
grade 3: deep ulcer with abscess or osteomyelitis
grade 4: gangrene forefoot (partial)
grade 5: extensive gangrene of foot

Question 4

what organism is responsible for cellulitis due to small breaks of skin? what about cellulitis due to larger wounds, ulcers, or abscesses?

Answer 4

• smaller wounds: strep

- larger wounds: staph

Question 5

how can the edema of venous insufficiency be differentiated from chronic lymphedema?

Answer 5

edema of venous insufficiency is softer, and there is often erythema, dermatitis, and hyperpigmentation along the distal aspect of the leg, and skin ulceration may occur near the medial and lateral malleoli

Question 6

what ABI score is associated with PAD?

Answer 6

less than 0.9

Question 7

what is the main use of D-dimer for DVT diagnosis? why?

Answer 7

• exclusion of thromboembolic disease where probability is low
• relatively sensitive, but poorly specific test for presence of DVT

Question 8

in order to treat DVT on an outpatient basis, the patient must fulfill what 3 criteria?

Answer 8

• hemodynamically stable
• good kidney function
• at low risk for bleeding

Question 9

what are the advantages that LMWH has over unfractionated heparin?

Answer 9

• longer biologic half life - can be administered subcutaneously once or twice daily
• lab monitoring NOT required
• thrombocytopenia is less likely although periodic monitoring of platelets may be needed
• dosing is fixed
• bleeding complications are less common
• can be used as outpatient

Question 10

what is one advantage of unfractionated heparin compared to LMWH?

Answer 10

can be immediately shut off and reversed with protamine due to short half life

Question 11

what is the only direct thrombin inhibitor available on the US market currently?

Answer 11

dabigatran

Question 12

what is a major advantage of dabigatran over other factor Xa inhibitors?

Answer 12

reversal agent available (idarucizumab)

Question 13

why cant direct thrombin inhibitors or factor Xa inhibitors be used in pregnant patients?

Answer 13

they cross the BBB

Question 14

direct thrombin inhibitors and factor Xa inhibitors cant be used in what patient populations?

Answer 14

• pregnant

- significant renal disease

Question 15

for a first time DVT that is provoked, how long must the patient be on anticoagulation?

Answer 15

3 months

Question 16

for a first time DVT that is unprovoked, how long must the patient be on anticoagulation?

Answer 16

3 months (may consider additional 3 months)

Question 17

what do you do when the INR is significantly overshot?

Answer 17

best option:

• hold warfarin
• give oral dose of vitamin K

second best option:

• DC warfarin
• repeat INR in 24 hours
• this is appropriate if the INR was between 5-9