Case Study For Complaining Of Leg Pain And Swelling Discussion

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 Complaining Of Leg Pain And Swelling Discussion.

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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 Complaining Of Leg Pain And Swelling Discussion. 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 Complaining Of Leg Pain And Swelling Discussion

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: 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. Case Study For Complaining Of Leg Pain And Swelling Discussion

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. Case Study For Complaining Of Leg Pain And Swelling Discussion

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Heme/lymphatic: denies any unusual bruising or bleeding, denies lymph node tenderness. Objective: 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)Case Study For Complaining Of Leg Pain And Swelling Discussion.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.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). 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?

Respond at least two times each to both of your colleagues who presented this week. The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to one of the three discussion prompts that your colleague provided in his or her video presentation. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient. Case Study For Complaining Of Leg Pain And Swelling Discussion

Rubric Detail

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Name: PRAC_6540_Week4_Grand_Rounds_Participant_Discussion_Rubric
Grid View
List View
Excellent Good Fair Poor
Responses
77 (77%) – 85 (85%)
Responses exhibit synthesis, critical thinking, and application to practice settings.

Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources.

Responses demonstrate synthesis and understanding of Learning Objectives.

Communication is professional and respectful to colleagues.

Presenters’ prompts/questions posed in the case presentations are thoroughly addressed.

Responses are effectively written in standard, edited English.
68 (68%) – 76 (76%)
Responses exhibit critical thinking and application to practice settings.

Responses provide clear, concise opinions and ideas that are supported by two or more credible sources.

Communication is professional and respectful to colleagues.

Presenters’ prompts/questions posed in the case presentations are addressed.

Responses are effectively written in standard, edited English.
60 (60%) – 67 (67%)
Responses are on topic and may have some depth.

Responses may lack clear, concise opinions and ideas, and only one or no credible sources are cited.

Responses posted in the Discussion may lack effective professional communication. Case Study For Complaining Of Leg Pain And Swelling Discussion

Presenters’ prompts/questions posed in the case presentations are inadequately addressed.
0 (0%) – 59 (59%)
Responses may not be on topic and lack depth.

No credible sources are cited.

Responses posted in the Discussion lack effective professional communication.

Responses to colleagues’ prompts/questions are missing.
Participation
14 (14%) – 15 (15%)
Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7.
12 (12%) – 13 (13%)
Meets requirements for participation by responding at least twice to each colleague who presented this week, over at least two days.
11 (11%) – 11 (11%)

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Participants respond at least twice to each colleague who presented this week, but responses may occur all in one day.
0 (0%) – 10 (10%)
Does not meet requirements for participation by responding at least twice to each colleague who presented this week.
Total Points: 100
Name: PRAC_6540_Week4_Grand_Rounds_Participant_Discussion_Rubric Case Study For Complaining Of Leg Pain And Swelling Discussion