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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of venous thromboembolism (VTE)

  • Identify elements needed for a proper diagnosis of deep venous thrombosis (DVT)

  • Develop a treatment and monitoring plan for patients with DVT

  • Select an appropriate bridging plan to oral anticoagulation

  • Educate a patient on anticoagulation therapy

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PATIENT PRESENTATION

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Chief Complaint

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"My left leg hurts so bad I can't handle it anymore."

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History of Present Illness

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Melinda Smith is a 38-year-old white female who presents to the emergency department with a 2-day H/O edema, severe pain, and warmth in her LLE. She returned home to Chicago, Illinois, 2 days ago from London, England, where she traveled for a long weekend (a gift from her husband). She reports that these symptoms developed after the flight. She had tried massaging her leg, but it is tender and painful to touch. She tried placing a warm towel on it to alleviate the pain, but she states that her leg has become increasingly warm since the symptoms appeared. She states she hates going to the doctor, so she did not want to have her symptoms evaluated initially 2 days ago.

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Past Medical History

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Tobacco use × 18 years

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Use of hormonal contraceptive × 5 years

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Obesity

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HTN × 2 years

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GERD × 10 years

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Occasional aches and pains

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Family History

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Mother: DVT age 63; per patient, she "took blood thinners"

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Sister: varicose veins

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Social History

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Patient works as a receptionist at a law office. She is married and lives with her husband of 10 years. They have two children aged 8 and 5 years.

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Tobacco/Alcohol/Substance Use

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(+) 1.5 ppd × 18 yr

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(+) Social drinker 2–3 drinks/wk

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(−) Denies illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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Amoxicillin (rash at age 3)

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Medications (Current)

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HCTZ 25 mg PO daily

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Omeprazole 20 mg PO (she states she takes it PRN)

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Norgestimate/ethinyl estradiol PO daily

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Ibuprofen 200 mg PO PRN headache or pain

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Multivitamin PO daily

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Review of Systems

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Occasional headaches and back pain relieved by ibuprofen

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Physical Examination

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General
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Obese, Caucasian woman in pain

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Vital Signs
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BP 132/78 mm Hg, P 68 bpm, RR 16, T 36.4°C

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Weight 220 lb (100 kg)

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Height 64 in. (163 cm)

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