Case Study For Patient With Leg Pain And Swelling

Patient Risk Factors for DVT

Advancing age is a major risk factor since patients over the age of 40 have a higher risk, which increases with each additional decade (Gregson et al., 2019). The patient is 67 years old and hence at higher risk. Being overweight and obese also increases the risk of DVT. The risk of DVT increases with weight, being twice as high in obese individuals as in normal-weight individuals. According to the BMI scale, the patient’s BMI of 27 is considered overweight. Another risk factor is smoking, which the patient has a history of smoking. Another risk factor is the minor injury the patient had on his leg which led to temporary immobilization (Zhang et al., 2019). Hypertension and myocardial infarction also increase the risk of DVT. The patient has been diagnosed with hypertension and is on medication. There is also a history of acute myocardial infarction in the patient’s immediate family (Gregson et al., 2019)Case Study For Patient With Leg Pain And Swelling.

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Patient Education while Taking Coumadin

A patient going home on Coumadin should be educated on drug adherence and the potential for side effects, drug interactions, drug-food interactions, and the activities to avoid. (Hawes, 2018) The patient should adhere to the prescribed drug (Coumadin), dose, frequency, and time. The patient should check on potential side effects such as stomach pain, nausea, vomiting, altered sense of taste, gas, or bloating which are normal and report to the doctor in case of severe side effects such as serious bleeding from a cut or nose bleeding. Foods rich in Vitamin K should be taken in moderation consistently. Blood tests will be performed once or more times a week and reduced to once a month if the results become stable. Some IV antibiotics belonging to fluoroquinolones, azole antifungals, and macrolide antibiotics are considered to be at high risk for interaction with warfarin (Wang et al., 2021)Case Study For Patient With Leg Pain And Swelling. The patient should also be advised to avoid activities that cause injury or bleeding. Also, to avoid smoking or consumption of alcohol.

References

Gregson, J., Kaptoge, S., & Bolton, T. (2019). Cardiovascular Risk Factors Associated With Venous Thromboembolism. JAMA Cardiol, 4(2), 163–173. https://doi.org/10.1001/jamacardio.2018.4537

Hawes, E. (2018). Patient education on oral anticoagulation. Pharmacy, 6(2), 34. https://doi.org/10.3390/pharmacy6020034

Wang, M., Zeraatkar, D., Obeda, M., Lee, M., Garcia, C., Nguyen, L., Agarwal, A., Al‐Shalabi, F., Benipal, H., Ahmad, A., Abbas, M., Vidug, K., & Holbrook, A. (2021). Drug-drug interactions with warfarin: A systematic review and meta‐analysis. British Journal of Clinical Pharmacology, 87(11), 4051-4100. https://doi.org/10.1111/bcp.14833

Zhang, W., Huai, Y., Wang, W., Xue, K., Chen, L., Chen, C., & Qian, A. (2019). A retrospective cohort study on the risk factors of deep vein thrombosis (DVT) for patients with traumatic fracture at Honghui hospital. BMJ Open, 9(3), e024247. https://doi.org/10.1136/bmjopen-2018-024247 Case Study For Patient With Leg Pain And Swelling

Patient info- Patient AS 67 year old caucasian male CC: Patient complains of Leg pain and swelling x 2 days HPI: Patient is 67 year old caucasian male states he slipped off the steps of his front door and fell 2 days ago, and hurt his right lower extremity. His leg started to swell and became more painful 1 day after the occurrence. Patient states that today his right lower extremity feels swollen even more and feels very tight. Patient states he believes he hit his leg on one of the steps when he fell. Patient rates pain a 5/10, the pain is now constant and is continuing to worsen. Pain in leg is worse when the patient tries to flex his lower leg and when he walks. He says it feels a little better when he is resting with his leg elevated. Past medical history: Case Study For Patient With Leg Pain And Swelling

Hypertension and allergic rhinitis, hospitalized for pneumonia 8 years ago. No surgical history. Family History: Father died at the age of 82 from an AMI. Mother died at the age of 88 from complications from Type II diabetes. Patient has one sister who has hypertension as well. He has two children who are alive and healthy at the age of 44 and 49. Social History: He is married and is a retired fire fighter. He is independent with his ADLs and lives with his wife. He states he and his wife currently exercise about 3 times per week which includes going to the mall in the morning for brisk walking for about 1 mile. He is a former smoker-1/2 pack/day but he states he quit about 30 years ago. He does drink alcohol occasionally if he is at a social event. He drinks caffeine (coffee, tea, or soda) 1-3 times daily. No illicit drug use. Allergies:NKDA Current medications: Amlodipine 10 mg PO QD, Claritin 10 mg tablet Immunization status:Up to date on all vaccines; He states he had his tetanus-diptheria booster 6 years ago and has had the herpes zoster vaccine. Flu and pneumonia vaccines given October 2021. Both covid vaccines received. Screening tests: lipid profile, PSA level, and other labs checked within last year. All lab work was reported normal. Colonoscopy at age 65. ROS: Constitutional symptoms: Patient denies fever, fatigue, chills, malaise, night sweats, unexplained weight loss Cardiovascular: Patient has a history of HTN. He states he was diagnosed several years ago but it is managed well with amlodipine. denies any chest pain, palpitations. Respiratory: Patient denies cough, SOB, difficulty breathing. MS: Reports pain and swelling in RLE, denies joint pain or change in ROM. Skin- denies rash, skin discoloration or any changes in moles. Heme/lymphatic: denies any unusual bruising or bleeding, denies lymph node tenderness. Objective: Case Study For Patient With Leg Pain And Swelling

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Vitals: temp 99.1, BP 133/81, hr 84, resp 18, 02 99%, BMI 27 General: Healthy appearing, well nourished, with no apparent distress, ambulating normally. Physical exam: CVS: Audible S1 S2, regular rate and rhythm ,no m/r/g. Pedal pulses +2 bilaterally. no cyanosis or clubbing. Resp: Lungs are clear to auscultation GI: Abdomen soft , non tender MS: RLE +2 pitting edema. redness, warmth noted. all other extremities normal exam. Skin: RLE warmth and redness, no scaling or breaks on skin, no rash, lesion or LLE discoloration. Labs and diagnostics CBC- to r/o cellulitis RFP- to check kidney function and baseline labs RLE Xray- rule out Tibial fracture US RLE- Ultrasound is the first-line imaging test for suspected DVT. D dimer- D-dimer levels are raised in most patients with DVT (sensitivity, 94–96%) and also in older patients and in patients with malignancy, sepsis, inflammation, chronic kidney failure, recent surgery, trauma, severe burns, and pregnancy (specificity, 42–52%) Assessment Primary Diagnosis DVT- Venous thromboembolism (VTE) most commonly manifests as lower extremity deep vein thrombosis (DVT) and pulmonary embolism and has an annual incidence of 1–2 per 1000 population.Symptoms and signs of leg or pelvis DVT include leg pain, swelling, erythema and dilated superficial veins. Arm DVT has similar symptoms localized to the arm. Some DVTs are asymptomatic. Differential diagnosis Cellulitis of RLE- Cellulitis is a bacterial infection of the skin, presenting with poorly demarcated erythema, edema, warmth, and tenderness.Cellulitis is a deep dermal and subcutaneous infection that occurs when pathogens gain entry into the dermis through breaks in the skin.Cellulitis usually presents as an acute, spreading, poorly demarcated area of erythema. The skin findings in cellulitis follow the classic signs of inflammation: dolor (pain), calor (heat), rubor (erythema), and tumor (swelling).Imaging studies are not diagnostic of cellulitis but can help distinguish it from more severe forms of infection and can identify drainable fluid collections, such as abscesses. Osteomyelitis can sometimes complicate cellulitis and when suspected can be best ruled out with magnetic resonance imaging or radiography. Case Study For Patient With Leg Pain And Swelling

Typical cases of non purulent cellulitis without systemic signs of infection (mild cellulitis) should be treated with anti-streptococcal antimicrobial agents such as cephalexin, dicloxacillin, penicillin VK, amoxicillin/clavulanate, or, in cases of penicillin allergy, clindamycin. R Tibial fracture- Tibial fractures occur in both high energy trauma, such as motor vehicle, winter sports (eg, skiing), and cycling accidents, and low energy trauma, such as falls, contact sports, distance running, and other endurance or repetitive impact activities. US doppler of venous RLE: result: there is a DVT in the right posterior tibial vein. A physical examination and X-rays are used to diagnose tibia and fibula fractures. Treatment for tibia and fibula fractures ranges from casting to surgery, depending on the type and severity of the injury. Plan – Patient sent to Emergency for further evaluation and management. Report called and given. Explained to patient what a DVT is and why he is being sent to the ED. Anticoagulation continues to be the cornerstone of therapy. The optimal anticoagulant and duration of therapy are determined by the clinical assessment. Anticoagulation is the mainstay of treatment for VTE; it aims to reduce mortality, thrombus extension, recurrence, and the risk of PTS (after DVT) and chronic thromboembolic pulmonary hypertension (after pulmonary embolism). Initial anti-coagulation therapy includes heparin intravenous therapy or enoxaparin subcutaneous injection which then be bridged to warfarin or rivaroxaban. Patient education is important to look for side effects and modify diet while taking anti coagulant therapy If skin breakdown observed wound culture be sent for microbiology and antibiotics are recommended. X-ray can rule out tibial fracture and if needed ortho consult can be ordered. Reference Fields, K. B. (2016). Overview of tibial fractures in adults. U: UpToDate, Post TW ur. UpToDate [Internet]. Waltham, MA: UpToDate. Kruger, P. C., Eikelboom, J. W., Douketis, J. D., & Hankey, G. J. (2019). Deep vein thrombosis: update on diagnosis and management. Medical Journal of Australia, 210(11), 516-524. Raff, A. B., & Kroshinsky, D. (2016)Case Study For Patient With Leg Pain And Swelling.

Cellulitis: a review. Jama, 316(3), 325-337. Discussion questions: What risk factors put the patient at risk for DVT? What education do we need for the patient’s anticoagulation going home: if the patient is going home on Coumadin what are the side effects, diet, labs to be drawn and how frequent? Is there an interaction between IV antibiotics and anticoagulants like Coumadin What other education can we provide to the patient post-discharge?Case Study For Patient With Leg Pain And Swelling