Transcript Case Report DVT/PE

Case Report
DVT/PE
Brenda Mertsock, PA-S
Lock Haven University
September 2008
Presenting Symptoms
This is what we saw!
 Patient drove herself to the ER
 CC: Shortness of Breath
 Tightness in her chest X a few hours.
 VS: 148/95, 82, 20, 98.2 F
 HPI: Included rt. leg was swollen, warm to touch,
and painful X 12 days.
 Pain was now a 3 out of 10, but it felt like a cutting,
tight rope pressure behind the knee that was much
more swollen and tender for the past 12 days.
HPI
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Aug, 1st, active doing yard work, felt pain behind the knee
Aug, 2nd, hauling logs, trimming trees, more physical activity, - swollen rt knee
Aug 3rd, knee so swollen, she reclined most of the day with it elevated, also noticed an exacerbation of low
back pain
Aug 4th, her usual chiropractor out of town, went to someone new, showed him her leg and he agreed it was
swollen and worked on her back
Aug 6th, her chiropractor back in town, he attributed her swollen leg to her back pain
Aug 7th, went to her primary care physician, he said her SI joint was out and that there was probably some
pooling from that.
No one ever made a measurement.
By this time, she felt like her skin could not stretch anymore, she elevated it every night, but nothing helped.
She continued to walk daily, work in her very busy professional business, and do household chores.
Aug 9th, her and her husband drove to North Carolina and then on Monday drove 10 hours back.
On Tuesday the 12th, she went to work and that evening was in the ER with SOB.
Tests Ordered & PE
Right lower leg moderate to severe tenderness,
CBC, BMP, D-Dimer, PT, PTT, cardiac
swelling, and warmth to the post rt. knee, calf,
enzymes, EKG, venous duplex of right lower
and rt. popliteal.
extremity, and a CT chest with IV contrast.
PE: no increased JVD or thyromegaly, lungs
were CTA Bilat., RRR, S1 and S2 with no
murmurs, + abd BS, soft, NT, no
oganomegaly, no guarding or rigidity,
portable chest x-ray was unremarkable.
Lungs were well expanded, unremarkable
heart, hila, and mediastinum.
Tenderness to a cord-like structure along the great
saphenous vein post. to the knee medially along
the thigh.
Recent Past Medical History
Past 6 mo. new onset of hypothyroidismtaking 25mg daily of Levothyroxine
Past 6 mo. New onset of menorrhagiataking Solia .15/.03mg
Past mo. skin rash- taking 5 mg
prednisone
Takes multivitamin and Oyster-D
Allergic to Penicillin
Differential Diagnosis
DVT
 Acute deep vein thrombosis of the right leg
popliteal vein, great saphenous vein
thrombosis- underlying etiology of Oral
contraceptives
 Chest pain ruling out PE or MI
 Hypothyroidism
Test Results
Pertinent lab results:
White ct – 12,700
Neutrophils- 90.4%
Negative cardiac enzymes
D-dimer- over 5000 ug/ml (0-300 ref range)
Venous Doppler showed rt common femoral
and femoral veins patent,
Rt popliteal vein was occluded and contained
thrombus with minimal flow, posterior tibial
vein appeared to be patent.
CT showed extensive pulmonary emboli
through-out the pulmonary arteries
bilaterally. This was so extensive there were
only a few branches that were not involved.
Treatment
Admit to hospital
with BRP only…
For 6 days
 Sub-Q Lovenox 100 mg/ml q 12 hr
 Use until therapeutic oral anticoagulation of
Coumadin is established with a level between 2
and 3.
 Pt will be on anti-coagulant therapy for 9 mo to
a year and monitor PT-INR.
 Pt was informed of risks and benefits of
treatment.
 Pt will continue on thyroid med, vitamins, and
discontinue OCP.
Why did it Happen?
Ethinyl estradiol and
norgestrel
Brand Names:
Cryselle 28
 Patient had no previous history of any type
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Lo/Ovral- 28
Low-Ogestrel-28
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Ogestrel-28
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of thrombolytic event.
Pt had no complications with previous oral
contraceptive use.
Pt had no contributory family history.
New onset of hypothyroidism and
contributing symptom of menorrhagia?
Maybe.
Reinstated use of Oral contracptives?
Maybe.
Oral Contraceptive Use
Solia
Equivalent to:
Desogen
Ortho-cept
 The pt. took Cryselle (2nd generation OCP)
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Apri
Reclipsen
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from Feb to May, could not tolerate it.
The pt. took Solia (3rd generation OCP) from
May to Aug.
2nd an 3rd generation OCPs contain different
levels of progestin.
2nd- Norgestrel
3rd- Desogestrel
What Happens?
 Desogestrel causes resistance to activated protein C (APC)
 Decreases total and free protein S
 Causes more pronounced APC resistance.
 When APC and protein S cannot perform their natural function
of inhibiting coagulation, clots tend to form more easily.
 Increasing the risk of venous thrombosis.
 If a pre-existing pro-thrombotic condition exists, the risk
increases 35-fold
What Happens
-600,000 episodes of PE in the US annually
-100,000 – 200,000 deaths
-Most not suspected or unrecognized
-Common cause of death a week to ten days after a
thrombosis formed.
-Proximal lower extremity venous thrombosis has been
reported to be the source of 90% of emboli.
-Symptoms of a PE could include; chest pain, dyspnea,
hemoptysis, JVD, fever, tricuspid regurgitation, increased
pulmonic heart tone, tachycardia, tachypnea, and pleural
effusion.
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Clinical Risk Factors for DVT/PE
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Age greater than 40
Previous DVT/PE
Surgery requiring anesthesia
for more than 30 min.
Prolonged immobilization
Stroke
Heart failure
Malignancy
Fractures of long bones or pelvis
Spinal cord injury
Obesity
Smoking
Pregnancy
- Renal failure
- Nephrotic syndrome
- Central venous catherization
- COPD
- Long distance travel
- Genetic or acquired
thrombophilia
-Inflammatory bowel disease
- Estsrogen therapy
Discussion
 At this time there is a petition to the US Food and Drug
Administration to ban third generation oral contraceptives
containing desogestrel. There have been documented case of
women of all ages experiencing DVTs from taking OCPs that
contain desogestrel.
 Pro-thrombotic blood tests are not routinely checked, so prior
knowledge is often unknown to the patient.
 Need to consider history, physical, and risks, when prescribing
OCPs.
References
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Demaria, Andrew (2001, February 5). Deep vein thrombosis explained. Retrieved September 4, 2008,
from CNN.com Web site:
http://archives.cnn.com/2001/WORLD/asiapcf/01/24/dvt.medical/
Drug Information Online. Retrieved September 5, 2008, from Drugs.com Web site:
http://www.drugs.com/drug_interactions.php?action=allinteractions&drugid=d03780&grugname=
desogestrel
Parkinson, MD, MPH, Jay, Park, MD, MPH, Sylvia, Wolfe, MD, Sidney M., & Rosendaal, MD, Frits (2007). Petition to
the FDA to Ban Third Generation Oral Contraceptives Containing Desogestrel due to Increased Risk of
Venous Thrombosis (HRG Publication # 1799). Protecting Health, Safety & Democracy, Retrieved Sept, 1,
2008, from http://www.citizen.org/publications/release.cfm?ID=7503.
Savelli, MD, Stephanie L., Kerliln, MD, Bryce A., Springer, MS, CGC, Michelle A., Monda, BSN, RN, Kay L., Thornton,
BSN, RN, Jennifer D., & Blanchong, MD, Carol A. (2006). Recommendations for screening for thrombophilic
tendencies in teenage females prior to contraceptive initiation. Journal of Pediatric and Adolescent
Gynecology 19, 1-8
Test, MD, FCCP, Victor J. (2008). Pulmonary Embolism. In Rakel & Bope: Conn's Current Therapy 2008, 60th ed.
[Web]. Saunders, An Imprint of Elsevier. Retrieved Sept 1, 2008, from
http://www.mdconsult.com/das/book/body/103887082 /0/1621/155.html?tocnode=54634409&fromURL=155.html#4-u1.0-B978-1-4160-4435-2..50081-9_1072
(2008, July 3). Cryselle 28. Retrieved September 5, 2008, from Consumer Drug Information Web site:
http://www.drugs.com/mtm/cryselle-28.html