Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT)

A 53-year-old man, Mr. Smith, a bus driver with a past medical history of type 2 diabetes, obesity, hyperlipidemia, smoking, and high blood pressure (hypertension), had presented with four days of left lower limb swelling, pain, and erythema. Physical examination revealed tenderness, erythema, warmth, and edema to his left leg, and this was found to have a circumference 35 cm longer than the right leg. The presentation of an ulcer on the plantar surface and loss of sensation in some areas signified the worsening of his chronic diseases. A Doppler ultrasound confirmed the diagnosis of DVT in the left femoral vein. This was supplemented by clinical examination and ultrasound findings, which are sensitive and specific modalities for diagnosing DVT. This case highlights the need for early diagnosis and management to avoid the consequences of DVT, including pulmonary embolism and post-thrombotic syndrome.

Differential Diagnoses

Two primary differential diagnoses were considered for Mr. Smith’s presentation: cellulitis and lymphedema. On the one hand, cellulitis is a bacterial skin infection that shows localized signs of erythema, edema, increased temperature, and tenderness, which are features of DVT (Brown & Hood Watson, 2021). Nonetheless, since the patient did not present with other symptoms like fever and chills, the diagnosis of cellulitis was dismissed due to the positive ultrasound findings. On the other hand, lymphedema, which results from lymphatic blockage, can mimic DVT, as noted by Sleigh and Manna (2023). Its common clinical manifestations are slow and localized development of swelling without significant pain, in contrast to DVT. Moreover, lymphedema is typically not erythematous and warm, which serves as an argument against its inclusion in the final diagnosis.

Diagnostic Plan

The first investigation performed on Mr. Smith was a Doppler analysis that indicated DVT in the left femoral vein. As Baker et al. (2021) pointed out, Doppler ultrasound is the most accurate method for diagnosing DVT because it presents a high sensitivity and specificity. This non-invasive test enables visualization of blood flow and depiction of thrombi in the veins, which makes it important for acute DVT diagnosis. While a D-dimer assay could be useful in allowing the diagnosis, it was not deemed relevant since the ultrasound findings were conclusive.

Treatment, Education, and Follow-Up

Initial Treatment Plan

The initial management of deep vein thrombosis includes anticoagulant therapy to stop the extension of the clot. Rivaroxaban, an oral anticoagulant, was initiated for Mr. Smith at an initial dose of 15 mg twice daily for the first 21 days and then a daily dose of 20 mg. Rivaroxaban was chosen because it is used in the same ways as warfarin, but there is no need for frequent monitoring of INR levels (Hua et al., 2020). Thirdly, the ulcer on the right foot of the client, Mr. Smith, needed cleaning, debridement, and proper dressing to avoid complications of infection and enhance healing. Since the patient had diabetes, importance was placed on foot care and regular check-ups, especially against conditions such as diabetic foot ulcers. Mr. Smith had two major chronic medical conditions that had to be addressed, namely poorly controlled diabetes with elevated blood glucose levels, hypertension, and hyperlipidemia that required statin therapy. Other preventive measures, including smoking, controlling weight, and exercising, were also suggested, as recommended by Grundy et al. (2019).

Patient Education

Mr. Smith was educated on the dosage, side effects, particularly bleeding due to anticoagulant drugs, and follow-up visits. He was also taught foot care measures to avoid complications from the ulcer. Teaching involved the consequences of non-compliance with the anticoagulant therapy and the possibility of re-thrombosis episodes.

Follow-Up Plan

Furthermore, clinic visits were scheduled to assess Mr. Smith’s reaction to anticoagulation therapy and the condition of the ulcer. The first follow-up was planned to be done after one week of admission, then one month for the first three months, and the next follow-up after three months. This schedule was to enhance the effectiveness of proper work and timely identification of any complication (Dineen-Griffin et al., 2019). For this reason, a high-risk patient with multiple co-morbidities, such as Mr. Smith, was first admitted to the hospital for stabilization, anticoagulation, and wound care management. In the subsequent management, the services of a vascular specialist, an endocrinologist, and a wound care nurse were employed.

Conclusion

DVT was an acute condition that presented acute symptoms and needed intervention in the short term in Mr. Smith, but it was also a chronic disease that required long-term management. The application of the clinical guidelines is supported by the Doppler ultrasound for the diagnosis and adherence to the management plan, including the prescription of rivaroxaban and appropriate wound care. Such patients should be followed up and taught how they can avoid a repeat of this condition. Therefore, compliance with contemporary guidelines for clinical practice can enhance the chances of obtaining the most favorable prognosis in patients with complications, including Mr. Smith.

References

Baker, M., Anjum, F., & dela Cruz, J. (2021). Deep Venous Thrombosis Ultrasound Evaluation. PubMed; StatPearls Publishing.

Brown, B. D., & Hood Watson, K. L. (2021). Cellulitis. PubMed; StatPearls Publishing.

Dineen-Griffin, S., Garcia-Cardenas, V., Williams, K., & Benrimoj, S. I. (2019). Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice. PLoS One, 14(8).

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., & Saseen, J. J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol. Circulation, 139(25).

Hua, Y., Sun, J.-Y., Su, Y., Qu, Q., Wang, H.-Y., Sun, W., & Kong, X.-Q. (2020). The safety and efficacy of rivaroxaban compared with warfarin in patients with atrial fibrillation and diabetes: A systematic review and meta-analysis. American Journal of Cardiovascular Drugs, 21(1), 51–61.

Sleigh, B. C., & Manna, B. (2023, April 19). Lymphedema. PubMed; StatPearls Publishing.

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Essay Elements: PLEASE MAKE SURE IT’S ONLY THREE PAGES LONG, NO MORE, NO LESS
• One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
• Brief introduction of the case
• Identification of the main diagnosis with supporting rationale
• Identification of at least two additional differential diagnoses with a brief rationale for why these were ruled out
• Diagnostic plan with supporting rationale or references
• A specific treatment plan supported by recent clinical guidelines
Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric:
• PLEASE USE CLINICAL GUIDELINES FOR REFERENCES IN APA FORMAT WITHIN THE LAST 5 YEARS.
• PLEASE SEE ATTACHED OUTLINE TO CREATE AN ESSAY

Summary:

Mr. Smith is a 53-year-old bus driver with a history of type 2 diabetes, hypertension, obesity, hyperlipidemia, and smoking who presents to an ambulatory family medicine practice with a four-day history of left lower extremity swelling and pain associated with erythema. On physical exam, Mr. Smith’s entire left lower extremity is tender, erythematous, warm, and swollen to 3.5 cm greater in circumference than his right. His feet are dry, and his toenails are dystrophic and incurvated. 3/10 sites are insensitive to a 10-gram monofilament test, and there is an ulceration present on the plantar surface of his left foot. The ulcer is appropriately graded, and a differential diagnosis is generated. After carefully considering the merits of obtaining a D-dimer test versus Doppler ultrasound to narrow the differential, a Doppler ultrasound is ordered, and the results confirm that Mr. Smith has a deep venous thrombosis (DVT) in his left femoral vein. An anticoagulation option is considered. Mr. Smith’s social situation is taken into account while creating a treatment plan. He is admitted to the hospital for anticoagulation, wound care, and coordination of appropriate care for his chronic health issues. Transition to long-term anticoagulation, duration of anticoagulation, and indications for thrombophilia workup are also addressed.

Just choose two Differential Diagnosis FROM THE LIST OF DIFFERENTIALS BELOW:
Differential diagnosis: Muscle strain, lymphedema, cellulitis, popliteal cyst, deep venous thrombosis, venous insufficiency, peripheral artery disease

Final diagnosis: Deep vein thrombosis (DVT

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