Case 7: Leg Swelling

Question 1

What is the single greatest contributor to death in the United States?

Answer 1

SMOKING

Question 2

Three leading causes of smoking attributable death

Answer 2

1. Lung cancer
2. Ischemic heart disease
3. COPD

Question 3

Uncontrolled hypertension reduces life expectancy by

Answer 3

20 years

Question 4

Four causes of hypertensive attributable death

Answer 4

1. Coronary artery disease
2. Hypertensive cardiomyopathy
3. Cerebrovascular disease
4. Chronic renal disease

Question 5

Two causes of diabetic attributable death

Answer 5

• cardiovascular disease

- chronic renal failure

Question 6

Risk of cardiovascular disease in diabetics is so high, it is assumed that

Answer 6

they have cardiovascular disease if they have diabetes

Question 7

Second most common cause of death in United States

Answer 7

Obesity

- reduces life expectancy by 6-7 years

Question 8

____% of PE are due to DVT

Answer 8

95%
PE carries high mortality (90% of deaths happen within first 2 hours) - so prevention and prompt Tx of DVT is key to reducing death as PE consequence

Question 9

Half life of warfarin

Answer 9

40 hours

Question 10

How long does it take for steady state of warfarin to be stable?

Answer 10

5 to 7 days

Question 11

Foot exam for Diabetic patients

Answer 11

1. Sensory testing with 10 g monofilament + any one of following:
   - vibration with 128 tuning fork
   - illicit Achilles ankle reflexes
   - pinprick sensation
2. Arterial supply assessment with DP/PT pulses + evaluate for skin changes: hair loss and temp changes
3. Inspect feet and footwear fit

Question 12

Strongest risk factor in delayed ulcer healing and amputation

Answer 12

Peripheral vascular disease

Question 13

Ulcer classification: Wagner Grading System

Answer 13

• Grade 1: Diabetic ulcer (superficial)
• Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
• Grade 3: Deep ulcer with abscess or osteomyelitis
• Grade 4: Gangrene forefoot (partial)
• Grade 5: Extensive gangrene of foot

Question 14

Ulcer management: Grade 1-2

Answer 14

• outpatient: extensive debridement + local wound care + relief of pressure

If erythema + purulent exudate: treat for infection

Question 15

Ulcer management: Grade 3

Answer 15

Evaluate for a) osteomyelitis and b) peripheral artery dz

- brief hospitalization

Question 16

Ulcer management: Grade 4-5

Answer 16

Emergent hospitalization + surgery consult –> amputation

Question 17

DDx for unilateral LE edema

Answer 17

• lymphedema
• cellulitis
• DVT
• venous insufficiency
• peripheral artery disease

Question 18

Lymphedema

Answer 18

Painless or dull heavy sensation in leg

• early stage: pitting
• chronic stage: limb has woody texture, tissue becomes indurated and fibrotic

Question 19

Cellulitis

Answer 19

Acute inflammatory infection of skin: erythema, swelling, heat (if small: strep, if large/ulcer/abscess: staph)
- RFs: diabetic nephropathy and PAD

Question 20

DVT

Answer 20

Swelling, pain, discoloration of affected extremity + palpable cord of thrombosed vein, warmth

• can result in chronic venous insufficiency (valves become thickened or high pressures distend vein and separate leaflets)
• pain is worse when standing and relieved w elevation
• inflammatory response in leg - mild fever

Doppler ultrasound is best test

Question 21

Venous insufficiency

Answer 21

Pitting edema + erythema + dermatitis + hyperpigmentation + skin ulceration near medial and lateral malleoli

Question 22

Peripheral artery disease

Answer 22

Atherosclerosis in peripheral vessels

• claudication
• ABI < 0.9
• greatest modifiable risk factor: smoking

Question 23

Most significant independent risk factors for DVT

Answer 23

• smoking

- obesity

Question 24

Wells criteria for Dx of DVT
Each +1 (8)
One is -2 (other dx is more likely than DVT)

Answer 24

Positive criteria

1. active cancer
2. paralysis, paresis, recent plaster immobilization of leg
3. recently bedridden >3 days or major surg w/in 4 wks
4. local tenderness along distribution of venous system
5. entire leg swollen
6. affected leg is swollen >3 cm compared to Asx leg
7. pitting edema > in Sx leg
8. collateral superficial veins (non-varicose)

Question 25

In order for DVT to be treated on outpatient basis: 3 patient reqs 2 home reqs

Answer 25

Patient reqs - hemodynamically stable - good kidney fxn - low risk for bleeding Home reqs - stable and supportive - daily access to INR monitoring

Question 26

Heparin allows for

Answer 26

Immediate inhibition of growth of thromboemboli by allowing fibrinolytic dissolution to be achieved unopposed

Question 27

Why is LMWH > unfractioned heparin

Answer 27

- longer biologic halflife (subQ once daily) - no lab monitoring required - thrombocytopenia is less likely - dosing is fixed * can be used in outpt setting Unfractionated heparin requires hospitalization as it is administered IV with dosage based on weight and titrated based on activated PTT

Question 28

LMWH can be substituted with

Answer 28

Fondaparinux (factor Xa inhibitor)

Question 29

Thromboprophylaxis can be achieved with

Answer 29

a) Warfarin | b) Factor Xa inhibitor

Question 30

Warfarin monitoring and titration

Answer 30

Titrate dose every 7 days to INR of 2-3

Question 31

Factor Xa inhibitors

Answer 31

Do not require weekly lab monitoring of INR so adherence is easier, but more expensive and harder to reverse anticoagulation in face of bleed

Question 32

First DVT or PE that is provoked by surgery or nonsurgical transient risk factor -- anticoagulate for?

Answer 32

3 months

Question 33

First DVT/PE that is unprovoked but bleeding risk is high, anticoagulate for?

Answer 33

3 months

Question 34

First DVT/PE that is unprovoked and bleeding risk is low/moderate, anticoagulate for?

Answer 34

Extended period of time

Question 35

First DVT/PE that is unprovoked and due to active cancer, anticoagulate for?

Answer 35

Extended period of time

Question 36

Patients with inherited coagulation disorders are anticoagulated

Answer 36

Indefinitely after episode of thrombotic disease

Question 37

Workup patient for inherited thrombophilia if (4)

Answer 37

1. Initial thrombosis when <50 without immediately identified RF 2. Family Hx of VTE 3. Recurrent venous thrombosis 4. Thrombosis in unusual vascular beds: portal, hepatic, mesenteric, cerebral veins

Question 38

If goal INR is substantially overshot...

Answer 38

1. Hold warfarin 2. Give ORAL dose of Vitamin K to reduce INR If INR 5-9 - dc wafarin, give oral K, repeat INR in 24 hrs

Question 39

How long to give LMWH, unfractioned heparin, or fondaparinux for as bridge to warfarin?

Answer 39

For at least five days + until INR is >2 for at least 24 hrs