Moderator True Anomaly Posted June 15, 2013 Moderator Share Posted June 15, 2013 On further thought, no need for the d dimer since we're doing the ultrasound, and we could go with a CT chest instead of a v/q There ya go :) If you're committed to doing an imaging study, the D-dimer is useless and wastes time. Plus, the "standard of care" is that the D-dimer is used in "low-risk Well's" patients, and as you've pointed out, she is moderate risk with her local tenderness and hx of prior DVT. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted June 15, 2013 Moderator Share Posted June 15, 2013 With her description of heart racing was an EKG done to r/o AFib? This would increase possibility of DVT as well. U/S or Doppler, Spiral CT to r/o PE, EKG to r/o AFib. Labs - I agree w/ above PT/PTT, D-Dimer (couldn't hurt), CBC How does atrial fibrillation increase the probability of a DVT that's not a PE? And why go with both a CT and an doppler? If you're going to irradiate, you can do "run offs" of the lower extremity vasculature. Link to comment Share on other sites More sharing options...
mdebord Posted June 15, 2013 Author Share Posted June 15, 2013 Ok! Sorry I've been away all day (traveling), but y'all have done an excellent job! (And thank you True Anomaly for the assist). So I called the ER to give them a heads up on pt's history and make them aware of my concerns. EKG: NSR, reg rate, intervals WNL, left axis, no hypertrophy, nl R wave progression, no evidence of ischemia/infarction. CBC: Hgb 7.2, Hct 24, WBC 9.0 with nl diff, Plts 290K. PT/PTT: WNL (don't remember exact values). D dimer not done because of high probability of positive. Doppler of LLE shows small acute DVT of the popliteal vein. CT NOT DONE IN ER! (This will be one of my "take home points" at the end, but for now, you do not have the information). Ok: So, any new ideas/confounding variables with this information? What do you want to initiate in the ER as far as treatment plan? Link to comment Share on other sites More sharing options...
PYRITE Posted June 15, 2013 Share Posted June 15, 2013 with previous hx of DVT I would admit and start her on heparin (if no previous hx I would consider outpatient treatment because it is in her calf) Link to comment Share on other sites More sharing options...
JoelleK Posted June 15, 2013 Share Posted June 15, 2013 H&H are low - provide possible transfusion to ensure hemodynamic stability and reverse the anemia. I think this can also cause in increase in the thickness of blood if done too quickly so I am not sure that it would be completely contraindicated to do the heparin to warfarin bridge. Also, there will need to be an investigation as to why she is anemic (acute pathology vs. chronic pathology). Link to comment Share on other sites More sharing options...
mdebord Posted June 15, 2013 Author Share Posted June 15, 2013 Good thoughts everybody. Remember I told you at the beginning that the anemia was chronic, due to menstrual bleeding, so I don't think a work-up is necessary there. I would have agreed to the admission, transfusion, and heparin. So here's what actually happened: Despite the DVT, the ER assumed that the dyspnea and racing heartbeat was due to anemia rather than a PE (hence why they didn't do the CT). They started her on ferrous sulfate TID and Lovenox and D/C'ed same day. Pt saw her Hematologist the next day, who immediately did a CT and told her "the reason your leg doesn't look worse is because it already traveled to your lung;" so there was in fact a significant PE. I saw her the following day and am currently bridging to Coumadin. Since starting blood thinners her SOB has improved. So these are the teaching points I wanted to discuss: 1) You have to take a complete history. In this case, she did not offer up the dyspnea - I had to specifically ask during the ROS. 2) Risk factors are important. Prior history, obese, intermittent hormone use, recent flying. Even though the exam was not impressive at all- you have to recognize the importance. Not every PE will present with vital sign or EKG changes. 3) Don't be dismissive. In this case, although there was an explanation for the dyspnea (anemia), that doesn't r/o another cause - PE. Fortunately everything worked out well in this case. Just a reminder to all of us to be thorough! *Thanks for bearing with me - This is the first time I've presented a case so I'm sure it was a little rocky! Link to comment Share on other sites More sharing options...
JoelleK Posted June 16, 2013 Share Posted June 16, 2013 Thanks for the case!!! I had forgotten about the chronic anemia :-) These are great and helpful! :-) Link to comment Share on other sites More sharing options...
PYRITE Posted June 16, 2013 Share Posted June 16, 2013 thanks, I really appreciate when people take the time to post these Link to comment Share on other sites More sharing options...
tigerlily Posted June 16, 2013 Share Posted June 16, 2013 mdebord, thanks for posting and taking the time to pass this on! Link to comment Share on other sites More sharing options...
GatorRRT Posted June 16, 2013 Share Posted June 16, 2013 Thanks, looking forward to your next case! Link to comment Share on other sites More sharing options...
nazmar Posted June 28, 2013 Share Posted June 28, 2013 I'm extremely Pre-PA, thus hardly understood anything that was written in shorthand - but still, I love reading these. Keep em' coming! Link to comment Share on other sites More sharing options...
mdebord Posted June 29, 2013 Author Share Posted June 29, 2013 I'm extremely Pre-PA, thus hardly understood anything that was written in shorthand - but still, I love reading these. Keep em' coming! Good thought! Next time I'll try to spell it out more clearly! Link to comment Share on other sites More sharing options...
nazmar Posted June 30, 2013 Share Posted June 30, 2013 Good thought! Next time I'll try to spell it out more clearly! Hey, it's no biggie! It gives me stuff to look up and learn for myself. Link to comment Share on other sites More sharing options...
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