7- DVT

Question 1

what is the single greatest contributor to death in this country

Answer 1

smoking

Question 2

The three leading specific causes of smoking-attributable death were

Answer 2

lung cancer

ischemic heart disease

COPD

Question 3

what is the single largest risk factor for cardiovascular mortality in the US.

Answer 3

HTN- decreases life by 20 years

Question 4

differential for unilateral leg swelling

Answer 4

cellulitis, lymphedema, or DVT

Question 5

differential for bilateral leg swelling

Answer 5

venous insufficiency or peripheral artery disease

Question 6

lymphedema

Answer 6

painless, but patients may experience a chronic dull, heavy sensation in the leg. starts in foot–>goes up

In the early stages of lymphedema, the edema is soft and pits easily with pressure.

In the chronic stages, the limb has a woody texture and the tissues become indurated and fibrotic.

Question 7

cellulitis

Answer 7

acute inflammatory condition -localized pain erythema, swelling, and heat.

Streptococcal infection : Small breaks of skin Staphylococcal cellulitis: larger wounds, ulcers, or abscesses.

diabetics more susceptible

Vascular disease contributes to the development

Question 8

Venous insufficiency

Answer 8

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.

Obesity is commonly associated

Question 9

Peripheral arterial disease

Answer 9

systemic atherosclerosis in arteries distal to the arch of the aorta.

history of claudication, which manifests as cramp-like muscle pain occurring with exercise and subsiding rapidly with rest. In addition, later in the course of the disease, patients may present with night pain, nonhealing ulcers, and skin color changes.

Question 10

ankle-brachial index (ABI) of what confirms peripheral artery disease

Answer 10

<0.9

Question 11

Which of the following diagnostic tests is the best initial test with high predictive value for determining whether your patient has cellulitis or DVT?

Answer 11

venous doppler of lower extremity

Question 12

what is D-dimer used for mostly?

Answer 12

exclude thromboembolic disease where the probability is low.

Question 13

what can predict pre-test probability of having DVT?

Answer 13

Well’s criteria

Question 14

labs to order to decipher between DVT and cellulitis

Answer 14

CBC
HgbA1c
BMP, BUN, Cr

Question 15

The Wagner Grading System

Answer 15

grade of ulcer

Grade 1: Diabetic ulcer (superficial)
Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
Grade 3: Deep ulcer with abscess or osteomyelitis
Grade 4: Gangrene forefoot (partial)
Grade 5: Extensive gangrene of foot

Question 16

grade 1 and 2 of wagner treatment

Answer 16

outpatient: extensive debridement, local wound care, and relief of pressure.

If significant erythema or purulent exudate, then treatment for infection is warranted.

Question 17

grade 3 wagner treatment

Answer 17

eval for osteomyelitis and PAD before address ulcer

at least a brief hospitalization is required to address these issues.

Question 18

grade 5 wagner treatment

Answer 18

emergent hospitalization and surgical consultation, often resulting in amputation.

Question 19

lethal consequence of DVT

Answer 19

PE (death within 1-2 hrs)

Question 20

In order to treat DVT on an outpatient basis…the patient must be

Answer 20

Hemodynamically stable
With good kidney function
At low risk for bleeding

The home environment must be Stable and supportive

Capable of providing the patient with daily access to INR monitoring (if using warfarin as the anticoagulant)

Question 21

outpatient treatments of DVT

Answer 21

rivaroxaban or apixaban alone
or
low molecular weight heparin (LMWH) overlapping with the initiation of warfarin

Question 22

inpatient treatment of DVT

Answer 22

unfrationated heparin overlapping with the initiation of warfarin

Question 23

Advantages of Low-Molecular Weight Heparin (LMWH) over Unfractionated Heparin

Answer 23

• -Longer biologic half-life so subQ 1-2x/day
• -Laboratory monitoring is not required
• -Thrombocytopenia less likely although periodic monitoring of platelets may be needed
• -Dosing is fixed
• -Bleeding complications are less common
• -can be used outpatient

Question 24

advantage to unfractionated heparin over LMWH

Answer 24

immediately shut off and reversed in the case of bleeding due to its very short half-life.

Question 25

warfarin needs to be titrated how frequently and to what dose of INR

Answer 25

very three to seven days to an INR of 2.0-3.0.

Question 26

warfarin disadvantages

Answer 26

highly variable dosing range,
frequent laboratory monitoring,
med-med interactions

Question 27

factor Xa inhibitors advantages

Answer 27

not requiring weekly lab monitoring of INR- adhere

just as effective and safer

Question 28

factor Xa inh disadvantages (Rivaroxaban and apixaban )

Answer 28

high cost and difficulty in reversing the anticoagulation in the face of a bleed.

Question 29

Direct thrombin inhibitors example

Answer 29

Dabigatran

Question 30

dabigatran advantages

Answer 30

oral- no lab monitoring

fewer bleeding consequences

Question 31

Recommended duration of anticoagulation normally (for reasons besides cancer)

Answer 31

3 months

Question 32

Criteria for Recommended Screening for Inherited Thrombophilia

Answer 32

Initial thrombosis occurring prior to age 50 without an immediately identified risk factor (e.g., idiopathic or unprovoked venous thrombosis).

A family history of venous thromboembolism.

Recurrent venous thrombosis.

Thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins.

Question 33

half-life of warfarin

Answer 33

40 hours, that means it will take five to seven days for the steady state to be stable.

wait this long to check INR before readjusting dose

Question 34

Recommended Action When Goal INR is Overshot

Answer 34

Discontinue warfarin, give Vitamin K 5 mg orally.

prevent bleeding!