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Medical Management

10 Mar 2008

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? ? ? ? ? ? ?

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These questions should be answered

What is the differential diagnosis and what are the possible cause of DVT ?

What is the best way to diagnosis or exclude DVT ?

What is the appropriate initial therapy of DVT ?

when is hospitalization not required ? What is the recommended long-term

treatment of DVT ?

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When should one screen for the presence of hypercoagulable state , not only in the patient , but also in family members ?

When patient should be referred for surgery ?

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1 ) What is the differential

diagnosis and what are the possible cause of DVT ?

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Differential Diagnosis

Popliteal (baker`s ) cyst Internal derangment of the knee Drug induced edema Calf muscle pull or tear Superficial thrombophelebitis Venous valvular insufficiency Lymphedema

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Possible causes : Risk Factors History of immobilization or prolonged

hospitalization/bed rest Recent surgery Obesity Prior episode(s) of venous

thromboembolism Lower extermity trauma Malignancy

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Use of oral contraceptive or hormones replacement therapy

Pregnancy or postpartum status stroke

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2 ) What is the best way to diagnosis or exclude

DVT ?

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Physical examination

Edema - 97 , 33 , and 70 percent

Pain - 86 , 19 , and 58 percent

Warmth - 72 , 48 , and 62 percent

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3) What is the appropriate initial therapy of DVT ?

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Treatment : LMW Heparin

Greater bioavailability Long duration of action Fixed does No lab test is necessary Lesser risk of thrombocytopenia

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4) when is hospitalization not required ?

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Who should not be hospitalized

The patient is ambulatory and in stable condition

There is a low prior risk of bleeding Severe renal insufficiency is not present There is a practical system in place for

monitoring of the patient

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5) What is the recommended long-term treatment of

DVT ?

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Long term treatment : Warfarin

Primary : 3-6 month Recurrent : more than 6-12 month Malignancy :LMW Heparin Pregnancy : LMW Heparin Isolated calf veins : 6-12 weeks High level of INR in first few days

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Indefinite anticoagulation

Two or more spontaneous thromboses One spontaneous life-threatening thrombosis One spontaneous thrombosis at unusual site One spontaneous thrombosis in the presence of

more then a single genetic defect predisposing to a thromboembolic event

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6) When should one screen for the presence of

hypercoagulable state , not only in the patient , but also in family members ?

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Who should be tested When thrombosis occurs in associations

with use of oral contraceptives , HRT or pregnancy

When thrombosis occurs in unusual vascular beds

In patients with the history of warfarin-induced skin necrosis

In patients with unprovoked upper extremity venous thrombosis

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Age under 50

Recurrent DVT

First degree relatives

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Who should not be tested

Recent major surgery , trauma or immobilization

Active malignancy Systemic lupus erythematosus Inflammatory bowel disease Myeloproliferative disorders Heparin-induced thrombocytopenia

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7) When patient should be referred for surgery ?

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