General Surgery Rotation

General Surgery: Deep venous thrombosis (ReelDx)

REEL-DX-ENHANCED

37 y/o with left lower leg swelling and pain, left-sided chest pain, and SOB

Patient will present as → a 78-year-old female complaining of generalized pain and edema in her left leg. She denies chest pain, shortness of breath, and hemoptysis. She takes 2.5 mg warfarin daily for atrial fibrillation and her INR is 2.6. On physical examination the patient experience calf pain with dorsiflexion of the left foot. The patient has a positive D-dimer and a lower extremity ultrasound reveals the presence of a deep venous thrombosis in the left popliteal vein.

Pain in what part of the body should always make you think of a DVT?
Calf pain

Caused by a clot formation in the veins. Virchow's triad determines risk factors for clot formation.

  1. Stasis: post-surgical, immobility, venous insufficiency.
  2. Hypercoagulable states: Factor V Leiden, cancer, OCP + smoking, pregnancy.
  3. Trauma: surgery, cellulitis.

Will present with edema of one extremity, and a positive Homan's sign (extend leg and push the foot towards the head with pain in the calf)

*Women over age 35 who smoke are at increased risk for the development of venous thrombosis and women older than 35 years who smoke should avoid oral contraceptive pills. Progestin-Only hormonal methods are a reasonable alternative in this population.

Venous duplex ultrasound is first line imaging test

  • D-dimer - a negative D-dimer will rule out DVT in low-risk patients
  • Venography is considered GOLD STANDARD

Treat with IV heparin and switch to Warfarin

  • Recurrent DVT requires lifetime anticoagulation

Adapted from surgical recall, by Lorne Blackbourne

osmosis Osmosis
Picmonic
Deep Vein Thrombosis (DVT) Management

deep-vein-thrombosis-dvt-management_5974_1492465438

Deep vein thrombosis (DVT) is a venous thromboembolism (VTE) that is often asymptomatic with clinical signs that are nebulous, including a combination of swelling, pain, and warmth. Diagnostic tests then become of utmost importance in determining the proper course of action. Diagnosis can be supported or accomplished via a variety of studies, including compression ultrasound (CUS) with doppler, D-dimer, and contrast venography. Treatment is dependent on a variety of factors, but options include heavy-hitting therapies such as an inferior vena cava (IVC) filter, heparin, warfarin, and thrombectomy/thrombolysis in addition to less aggressive, preventative measures such as compression stockings and walking.

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Deep Vein Thrombosis (DVT) Characteristics

Deep vein thrombosis (DVT) is a serious complication in patients with specific risk factors. Patients who fulfill any part of Virchow’s triad may develop DVT, which presents as redness, swelling, warmth, tenderness, and a positive Homan’s sign. Often, patients can be asymptomatic.

Play Video + Quiz

Question 1
A 36 year-old female presents for a refill of her oral contraceptives. She admits to smoking one pack of cigarettes per day. She should be counseled with regard to her risk of
A
venous thrombosis.
B
varicose veins.
Hint:
Varicose veins are the result of pressure overload on incompetent veins and not due to the use of oral contraceptives.
C
atherosclerosis.
Hint:
The defined risks of atherosclerosis includes smoking, but does not include the use of oral contraceptives.
D
peripheral edema.
Hint:
There is no relationship between the use of oral contraceptives and the development of peripheral edema.
Question 1 Explanation: 
Women over age 35 who smoke are at increased risk for the development of venous thrombosis and women older than 35 years who smoke should avoid oral contraceptive pills. Progestin-Only Hormonal Methods are a reasonable alternative in this population.
Question 2
Which of the following diagnostic tests should be ordered initially to evaluate for suspected deep venous thrombosis of the leg?
A
Venogram
Hint:
Venogram has been replaced by noninvasive tests due to discomfort, cost, technical difficulties, and complications, such as phlebitis.
B
Arteriogram
Hint:
Thrombophlebitis is a venous problem, not an arterial one. Any unnecessary invasive procedure is potentially harmful.
C
Duplex ultrasound
D
Impedance plethysmography
Hint:
Impedance plethysmography is equivalent to ultrasound in detecting thrombi of the femoral and popliteal veins, but it may miss early, nonocclusive thrombi.
Question 2 Explanation: 
Ultrasound is the technique of choice to detect deep venous thrombosis in the leg.
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