Leg Swelling

Question 1

Most significant causes of death

Answer 1

Smoking
Obesity
Diabetes
HTN

Question 2

What percent of deaths due to PE occur within 1 to 2 hrs?

Answer 2

90%

Question 3

What is the half-life of warfarin?

Answer 3

40 hrs

- 5 to 7 days to reach steady state

Question 4

What is an important part of the diabetic foot exam that is often overlooked?

Answer 4

Inspecting the footwear

Question 5

Diabetic foot ulcers
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5

Answer 5

Superficial
Ulcer extension (Tendons, ligaments, joint capsule, fascia)
Abscess or osteomyelitis
Gangrene of forefoot
Extensive gangrene

Question 6

Chronic dull, heavy sensation in leg

Answer 6

Lymphedema

Question 7

Small breaks in skin (Cellulitis)

Answer 7

Strep infection

Question 8

Large wounds, ulcers, or abscess (Cellulitis)

Answer 8

Staph

Question 9

Risk factors for cellulitis

Answer 9

Diabetes

Vascular disease

Question 10

“Palpable cord”, superficial venous dilation

Answer 10

DVT

Question 11

Granulocyte infiltration, loss of endothelium, and edema

Answer 11

Inflammatory process associated with DVTs

Question 12

Most robust risk factors for DVT

Answer 12

Smoking

Obesity

Question 13

Basics of DVT wells score

• 0 = Low probability
• 1 to 2 = Moderate probability
• 3+ = High probability

Answer 13

Active cancer
Immobilization of legs
Bedridden (3 days) or Major surgery (Last 4 weeks)
Local tenderness along deep venous system
Entire leg is swollen
Calf swollen > 3 cm compared to normal leg
Pitting edema
Collateral superficial veins
Alternative dx more likely (-2)

Question 14

Test to help determine DVT vs Cellulitis

Answer 14

CBC
Venous doppler (Sensitive & Specific)
D-dimer (Sensitive, but not specific)

Question 15

Treatment of grade 1 or 2 ulcers

Answer 15

Outpatient

• Debridement
• Wound care
• Decrease pressure
• Treat infection as needed

Question 16

Treatment of grade 3 ulcer

Answer 16

Rule out osteomyelitis & PAD

- May require inpatient treatment

Question 17

Treatment of grade 5

Answer 17

Inpatient

• Surgical consult
• Good chance of amputation

Question 18

Requirements for outpatient treatment of DVT

Answer 18

Stable
Good kidney function
Low risk for bleed

Question 19

Goals of DVT treatment

Answer 19

Stop growth
Promote resolution
Prevent recurrence

Question 20

Benefits of LMWH

Answer 20

Longer 1/2 life = Sub Q administration
No monitoring 
Lower risk of thrombocytopenia
Fixed dosing 
Can be used outpatient

Question 21

Why heparin is an inpatient medication

Answer 21

Requires IV dosing based on body weight

Must be titrated to aPTT

Question 22

How often should you titrate warfarin

Answer 22

every 3 to 7 days

Question 23

Which Xa inhibitor can be used instead of heparin

Answer 23

Fondaparinux

Question 24

Length of anticoagulation
Provoked
Unprovoked
Thrombophilic disorder

Answer 24

Provoked:
- 3 months regardless of cause or bleeding risk
Unprovoked:
- 6 months if low risk for bleed or active cancer
- 3 months if high risk for bleed
Thrombophilic disorder
- Indefinitely

Question 25

Indications to screen for thrombophilic disorder

Answer 25

Onset before age 50 with out risk factors
Family history
Recurrent thrombosis
Portal, heaptic, mesenteric, or cerebral thrombrosis

Question 26

How to respond to high INR (> 9)

Answer 26

Hold warfarin

Give oral vitamin K

Question 27

What if INR was between 5 and 9

Answer 27

Hold warfarin and check INR in 24 hrs

Question 28

When can you stop the bridge to coumadin

Answer 28

Bridge must last at least 5 days

INR must be >/ 2 for at least 24 hrs