Thromboembolitic Dx

Question 1

What is Venous thromboembolism

Answer 1

Blood clots forms in the vein which can break free and enter circulation as an embolus and lodge and obstruct a blood vessel

Question 2

Most common type of Venous thromboembolism

Answer 2

Deep vein thrombosis

Question 3

What is the name of a superficial venous thrombosis

Answer 3

Phlebitis or superficial thrombophlebitis

Question 4

Main Origin of DVT

Answer 4

Leg starting at the calf

Question 5

Virchow triad

Answer 5

Venous stasis
Endothelial damage
hypercoagulable state

Question 6

Factors contributing to venous stasis

Answer 6

Prolonged bedrest
cast on the leg
Limb paralysis from stroke or spinal cord injury
extended travel in vehicle

Question 7

Factors contributing to hypercoagulable state

Answer 7

Surgery and trauma which decrease flow of blood increasing chances of blood clots, and general anesthetic used lead to venous vasodilation which increases chances of clots

Malignancy
increased estrogen
all stages of pregnancy
first three months postpartum
elective abortion
oral contraceptive pills

Question 8

Inherited disorders of coagulation

Answer 8

Protein s, c or antithrombin III deficiencies

Question 9

Acquired Disorders of coagulation

Answer 9

Nephrotic syndrome with urinary loss of antithrombin III
antiphospholipid antibodies accelerating coagulation

Question 10

Inflammatory disease leading to to hypercoagulability State

Answer 10

SLE
sickle cell disease
IBD

Question 11

Factors causing endothelial injury

Answer 11

Trauma
surgery
invasive procedures
Iatrogenic - cv catheters

Question 12

PathoPhysiology of DVT

Answer 12

Conversion of prothrombin to Thrombin
Fibrin deposition
Coagulation cascade
Propagation of clot due to risk factors
Embolism

Question 13

Majority of cases how many legs are affected individuals

Answer 13

1

Question 14

Clinical presentation of DVT

Answer 14

Calf pain or tenderness
Warm local skin
Swelling below the knee indistal DVT
Swelling up to groin in proximal DVT
Superficial venous dilatation
Redskin
cyanosis
leg fatigue

Question 15

Examination hallmarks in DVT

Answer 15

Palpate distal pulses
capillary refill
palpation and movement of all joints for acute arthritis
Homans sign - Pain in posterior calf or knee with forced Dorsiflexion of the foot
while knee is fully extended
Exam of possible underlying factors

Question 16

Signs of pulmonary embolism

Answer 16

Breathlessness
chest pain
coughing with blood stains sputum
hemoptysis
Wheezing
lightheadedness
fainting
Unexplain anxiety
accelerated heartbeat

Question 17

Wells clinical prediction guide for DVT parameters

Answer 17

Active cancer
paralysis or Recents immobilization
Recent bedridden for more than three days or major surgery
localized tenderness
entire leg swelling
calf swelling more than 3 cm
Pitting edema
collateral superficial veins
alternative diagnosis

Question 18

Investigation of DVT

Answer 18

Blood test- d dimers and INR
imaging studies

Question 19

Techniques to measure d dimer

Answer 19

Elisa
Latex agglutination
blood agglutination test

Question 20

Imaging in DVT

Answer 20

Venography
Radiolabeled fibrinogen
Ultrasound
Plethysmography
Mri

Question 21

Differentials of DVT

Answer 21

Cellulitis
thrombophlebitis
arthritis
Asymmetric peripheral edema due to congestive heart failure,liver disease ,renal failure or nephritic syndrome
lymphangitis
hematoma
lymphedema
ruptured baker cyst
superficial thrombophlebitis
varicose veins

Question 22

Treatment options of DVT

Answer 22

Anticoagulation
thrombolytic therapy
surgery
filters
compression stockings

Question 23

Types of anticoagulation

Answer 23

Heparin
warfarin

Question 24

Percentage of DVT occuring in deep veins of upper extremities

Answer 24

4-13%

Question 25

Most commonly affected veins of leg

Answer 25

Superficial femoral vein Popliteal vein Posterior tibial vein Peroneal vein

Question 26

Main cause of upper extremities DVT

Answer 26

Endothelial injury caused by central venous catheter , pacemakers , injection drug use Superior vena cava syndrome Subclavian vein compression at thoracic outlet from normal or accessory 1st rib or fibrous band

Question 27

Common complications of DVT

Answer 27

Pulmonary embolism Postphlebitic syndrome Chronic venous insufficiency

Question 28

Less common complications of DVT

Answer 28

Phlegmasia alba dolens Phlegmasia cerulean dolens Venous gangrene Thrombophlebitis

Question 29

Symptoms and signs of superficial thrombophlebitis

Answer 29

Palpable, indurated, cordlike, tender, subcutaneous venous segment

Question 30

Unilateral leg swelling differential

Answer 30

DVT Cellulitis Ruptured Baker cyst Harmatoma Trauma Lymphoedema Tendonitis

Question 31

Differential of bilateral leg swelling

Answer 31

DVT Drugs - CCB Right heart failure Hypoalbunemia Liver failure Chronic kidney disease

Question 32

Wells criteria for assessment

Answer 32

Active cancer Paralysis, paresis, or recent cast immobilization of the lower extremities Recently bedridden >3 days or major surgery within 4 weeks Localized tenderness along the distribution of the deep venous system Swelling of entire leg Calf swelling by >3 cm compared to the asymptomatic leg (measured 10 cm below tibial tuberosity) Pitting edema (greater in the symptomatic leg) Swollen unilateral superficial veins (nonvaricose) Alternative diagnosis as likely as or more likely than deep vein thrombosis

Question 33

If wells criteria is low what are your next steps in investigations

Answer 33

Check D dimer , If positive then do emergency Doppler US If negative then exclude DVT

Question 34

If wells criteria is moderate or high what are your next steps in investigations

Answer 34

Emergency Doppler US If negative do D dimer If positive do anticoagulation therapy

Question 35

What is d dimer

Answer 35

Product of fibrinolysis , indicates presence and lysis of thrombi

Question 36

Medical conditions SSOCIATED WITH ELEVATED D DIMER

Answer 36

Liver disease Trauma Pregnancy Infection Rheumatoid factor positive Inflammation Cancer Recent surgery Intracardiaque thrombi SSdx Nephrotic syndrome Acute renal failure

Question 37

Goal of treatment of DVT

Answer 37

PE prevention Symptom relief Prevention of DVT recurrence, and complications

Question 38

DVT treatment

Answer 38

Initial - injectable heparin unfractioned or LMWH Longer treatment within 24-48h - vitamin K antagonist like warfarin , factor Xa inhibitors like Rivaroxaban or apixaban , direct thrombin inhibitors like dabigatran Systemic thormbolytic therapy (tPA, streptokinase, urokinase )

Question 39

Supportive measures in DVT

Answer 39

Analgesics 3-5 NSAIDS Elevation of legs by pillow

Question 40

Duration of DVT treatment t

Answer 40

With transient risk factors 3-6 months Non modifiable risk factors , idiopathic DVT or recurrent DVT at least 6 months

Question 41

Most common complication of DVT treatment

Answer 41

Bleeding

Question 42

Where do you place inferior vena cava filter

Answer 42

IVC below renal veins via catheterization of internal jugular vein or femoral vein

Question 43

Examination of DVT

Question 44

Heparin monitoring in DVT