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Old 10-20-2011
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Vascular Treatment of DVT

A 38-year-old woman with a 10 pack-year history of smoking comes to the urgent care clinic because of left calf pain of 1 day’s duration. For the last 2 to 3 days her left leg has been slightly swollen and there has been tenderness over the calf muscles of the same leg. She denies recent travels, trauma to her extremity, and history of any medical condition, and only takes oral contraceptives prescribed 3 years ago by her gynecologist. Other than this the patient has always been in excellent health. She denies shortness of breath, cough, chest pain, or other symptoms. On exam, her vital signs are within normal limits. Her left leg is greater in circumference than the right, and there is pain in the calf of the left leg on dorsiflexion of the left foot. There is no noticeable redness and no bulging or fullness of the popliteal space. The rest of the physical examination is unremarkable. You send the patient to the hospital and order a duplex ultrasound of the lower extremity, which is reported as: “A clot is seen in the popliteal vein extending to the midthigh.” Which of the following is the most appropriate next step in management?
A. Admit the patient to the hospital and start a heparin drip for a period of 5 to 7 days; add warfarin on the second day to achieve an INR of 2–3
B. Discharge the patient home and ask her to return if she has any difficulty breathing, chest pain, or cough
C. Discharge the patient home and repeat the duplex ultrasound in 48 hours
D. Discharge the patient home on low molecular-weight heparin; tell her to follow up with her primary care physician in 3 to 5 days to check her PTT
E. Admit the patient to the hospital and start warfarin; check her PTT in 2 to 3 days and discharge after PTT is 2 to 3 times normal
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Old 10-20-2011
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A. Admit the patient to the hospital and start a heparin drip for a period of 5 to 7 days; add warfarin on the second day to achieve an INR of 2–3
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A. Admit the patient to the hospital and start a heparin drip for a period of 5 to 7 days; add warfarin on the second day to achieve an INR of 2–3
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Old 10-21-2011
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A. Admit the patient to the hospital and start a heparin drip for a period of 5 to 7 days; add warfarin on the second day to achieve an INR of 2–3
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The correct answer is A. This patient has a DVT, most likely caused by the combination of smoking and oral contraceptives. She needs anticoagulation, since the duplex ultrasound showed a clot in the popliteal vein above the knee.

Discharging the patient home and asking her to return if she feels any difficulty breathing, chest pain or cough (choice B) is incorrect. You need to anticoagulate this patient now, not when she develops a pulmonary embolism.

Discharging her home and repeating duplex ultrasound in 48 hours (choice C) is incorrect. This choice is incorrect also because the patient’s clot is above the knee. You would have the patient return in 48 hours to repeat the duplex ultrasound only if the clot in her leg were below the knee.

Discharging the patient home on low molecular-weight heparin, to follow up with her primary care physician in 3 to 5 days to check her PTT (choice D) is incorrect. Another anticoagulation option is for her to use low molecular-weight heparin as an outpatient and start warfarin; but with low molecular-weight heparin, it is not necessary to follow PTT.

Starting warfarin and checking her PTT in 2 to 3 days, then discharging her after PTT is 2 to 3 times normal (choice E) is incorrect, for two reasons. First, you don’t follow PTT with warfarin; you follow PT/INR. Second, you must have an overlap with heparin when anticoagulating the patient with warfarin to avoid the initial hypercoagulable states that present with warfarin
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