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
"My left leg hurts so bad I can't handle it anymore."
History of Present Illness
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.
Use of hormonal contraceptive × 5 years
Occasional aches and pains
Mother: DVT age 63; per patient, she "took blood thinners"
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.
(+) Social drinker 2–3 drinks/wk
(−) Denies illicit drug use
Allergies/Intolerances/Adverse Drug Events
Amoxicillin (rash at age 3)
Omeprazole 20 mg PO (she states she takes it PRN)
Norgestimate/ethinyl estradiol PO daily
Ibuprofen 200 mg PO PRN headache or pain
Occasional headaches and back pain relieved by ibuprofen
Obese, Caucasian woman in pain
BP 132/78 mm Hg, P 68 bpm, RR 16, T 36.4°C