Pathophysiology of a DVT Paper Example

Introduction

DVT forms in both upper and lower extremities with lower extremity accounting for 96% of DVT cases. Lower extremity DVT arises from endothelial dysfunction or injury, venous return impairment, and hypercoagulability. On the other hand, upper extremity DVT may occur due to endothelial injury from pacemakers, central venous catheters as well as injection. However, as part of superior vena cava syndrome as well as a result of vein compression at the subclavian or hypercoagulable state that may occur at the thoracic outlet, DVT may occur. Compression is caused by either thoracic outlet syndrome or strenuous activities of the arm. This accounts for the 4% of the upper extremity's DVT cases of effort thrombosis or Paget-Schroetter Syndrome. Most cases of DVT are reported to start from the cusps of the venous valves. The condition is characterized by thrombi consisting of thrombin, fibrin, RBCs along with a few platelets. Lack of medication may lead to the proximal propagation of the thrombi or towards the lungs.

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Tests to be included in a coagulation panel

Coagulation panel entails the tests confirming hypercoagulability of DVT. These tests may include blood tests such as checking the D-dimer level in the blood (Kearo et al., 2015). D-dimer levels increases in people with blood clots (Linkins et al., 2013). A positive D-dimer test shows the possibility of DVT. However, suspicion on the results may necessitate imaging tests such as Doppler ultrasound which deploys sound waves in generating pictures of blood vessels. In case Doppler ultrasound is not feasible, Contrast venogram is applied which uses a catheter and a dye in illuminating the blood vessel. However, in the case of contrast venogram cannot be performed effectively, magnet resonance imaging (MRI) is carried out which use a magnet in creating images of internal body parts (Houshmand et al., 2014). Additionally, Computed Tomography (CT) venography and MRI venography are used in evaluating blood clots in the abdomen or pelvis. Imaging tests provide the images of the clots and veins.

Thrombolysis and why it was included in the original treatment of the DVT

Thrombolysis performs breakdown of a blood clot. DVT entails formation of a clot in the veins, thrombolysis was used in the initial treatment to facilitate breakdown and dissolving of the clot. The effectiveness of thrombolysis is higher compared to the standard anticoagulant therapy offered to DVT patients.

Questions to include in the review of systems during completion of history and physical examination

• Do you have any history of DVT? Any family member with a history of thrombosis?

Yes. Ten years ago, I was diagnosed with DVT which was treated. My mother also recorded a case of DVT last year.

• Do you have any swelling in your legs or calf? Is it painful?

Yes. My left calf has indicated some swelling with the physical protrusion of veins on the surface of the vein. My left thigh too has shown slight swelling in the last few weeks.

• Any allergic condition? Any other history of a medical condition?

No. I don't have any allergic condition but I am asthmatic and hypertensive.

History and physical examination

The patient records a follow up after hospitalization for a left leg Deep Vein Thrombosis. The patient was administered on rivaroxaban on the previous treatment. According to the patient, the swelling and tenderness were reported to decrease. Additionally, the patient tested positive for Factor V Leiden. The patient recorded a temperature of 37 degrees Celsius, the heart pulse rate of 70 beats per minute, and a respiratory rate of 17 breaths per minute. Additionally, a blood pressure of 160/92 was also recorded. According to van Bellen et al. (2014), any history of DVT indicates high signs of getting DVT again. On the other hand, cases of family history of DVT with the diagnosis of Factor V Leiden turning out positive is an indication of the chances of DVT testing positive in patients. Since the patient's condition is not advanced, use of anticoagulants was administered to aid in the breakdown of the clot. Factor V Leiden is a disorder which exposes individuals to high risks of Deep Venous Thrombosis. The low blood pressure recorded provides the blood vessels with the ability to support and maintain blood flow in the veins without exposing the veins to tension and pressure.

However, since the patient was hospitalized over DVT, an assessment to rule out recurrent DVT condition in the patient. On the other side, an assessment of the presence of Post Thrombosis Syndrome (PTS) to examine the symptoms of the disorder since it is common in DVT patients (Prandoni et al., 2015). PTS cause pain and tenderness in the DVT affected leg.

The patient reported being asthmatic as well as hypertensive the blood pressure and respiratory rate need to be evaluated too. Some of the symptoms of asthma mimic the signs of DVT and therefore a critical evaluation eliminates chances of misdiagnosis. The patient was subjected to rivaroxaban to prevent further generation of the clot. in this case, according to Huisman & Klok (2013), anticoagulants are the most suitable drugs used to treat DVT in case the condition (Huisman & Klok, 2013)

Selection of rivaroxaban

Rivaroxaban is used since unlike warfarin, overlapping with heparins is not necessary (Prins et al., 2013). Rivaroxaban functions by blocking active sites of factor Xa inhibiting its function. Additionally, it does not require monitoring as well as overlapping and the risks of bleeding are lower compared to warfarin.

On diagnosis with DVT administration of 15 mg of rivaroxaban is initiated immediately twice a day. 15 mg of rivaroxaban is administered for 3 weeks twice a day and then adjusted to 20 mg once a day. However, on continuity with treatment, 20 mg once a day is administered. DVT is recurrent and therefore the accompanying dosage is used to reduce the risks of recurrence (Mueck et al., 2014). The change to 20 mg once a day is for maintenance purposes.

Reducing the dosage to 10 mg per day for after the initial dosage. The changer will facilitate elimination of risk factors in line with recurrent DVT.

How long a patient needs to be on rivaroxaban

A patient can be on rivaroxaban for 3 to 6 months depending on the response of the clot to the drug (Long et al., 2014). However, it is recommended to keep taking the drug until imaging tests show the clot degenerates. Since DVT has a tendency of recurring, it is advisable to maintain rivaroxaban administration until full recovery to avoid recurrence. However, the mean treatment duration on the drug is 208 days giving the patient 208 days of use of the drug.

Current medication

The current medication is appropriate since rivaroxaban is administered to counter the DVT, 25 mg of HCTZ administered in relation to hypertension while 250/50 of Advair used for the treatment of asthma. Ibuprofen 400-600 mg is a painkiller to relieve pain from the swollen, tender and painful leg. The medication is appropriate since it addresses the medical conditions of the patient considering the patient's medical history.

Treatment plan and patient education

The treatment plan for DVT depends on the results of the scans carried out. Treatment is done by various medicines as well as devices that facilitate therapy. Treatment of DVT aims at stopping the advancement of the clot, prevention of blood clot from breaking off and moving to the lungs and prevention of experiencing a recurrent in blood clotting. The drugs used in venous thromboembolism therapy include anticoagulants which may be intravenous, subcutaneously or orally administered (Lindhoff-Last et al., 2013). Parenteral agents applied in the treatment of the DVT include unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux and rivaroxaban. However, rivaroxaban is administered orally.

In this case, the patient was subjected to rivaroxaban since it inhibits factor Xa by binding to the active site of factor Xa hence eliminating the growth of the clot. additionally, since the treatment is focused on an outpatient, oral medication is more convenient for outpatients. The need for daily injections renders intravenously and subcutaneously administered drugs less effective to outpatients. Blood thinners, commonly referred to anticoagulants used in the treatment of DVT are heparin and warfarin whose administration is started at the same time but when warfarin starts working heparin is stopped. However, due to the improvements in the treatment of drugs, drugs like rivaroxaban have been introduced which do not require heparin overlapping.

Comparing the efficiency of warfarin and rivaroxaban, rivaroxaban indicates fewer chances of bleeding risks, food interaction and close monitoring. Therefore, the patient can easily take the medication in relation to the instructions of the physician. This doe does not need close monitoring since it poses less risk of bleeding. Compression stockings are also used in the treatment of DVT. However, most compression stockings use is limited to post-surgery which hinders the development of DVT and post-surgery swelling that may occur in a patient (Sachdeva et al., 2014).

The patient was subjected to rivaroxaban owing to its ease of use and administration. The drug is taken orally and hence easier for the continued patient use. Additionally, the patient required pain relievers for the pain in the swollen leg. Since the patient has a history of asthma and hypertension, asthmatic drugs (Advair 250/50 per day), as well as hypertension drugs (HCTZ 25 mg per day), need to be administered too. Since the patient was on outpatient, rivaroxaban is the most effective treatment since it requires less monitoring as compared to warfarin which calls for monitoring of other drugs and the diet. High contents of vitamin K inhibits the function of warfarin (Lip et al., 2016). In terms of the duration, the patient will be rivaroxaban, it will base on the recovery rate. However, a six-month period is recommended for the patient to allow full recovery of the clot.

References

Houshmand, S., Salavati, A., Hess, S., Ravina, M., & Alavi, A. (2014). The role of molecular imaging in diagnosis of deep vein thrombosis. American journal of nuclear medicine and molecular imaging, 4(5), 406.

Huisman, M. V., & Klok, F. A. (2013). Diagnostic management of acute deep vein thrombosis and pulmonary embolism. Journal of Thrombosis and Haemostasis, 11(3), 412-422.

Kearon, C., Spencer, F. A., O'keeffe, D., Parpia, S., Schulman, S., Baglin, T., ... & Lentz, S. R. (2015). D-dimer testing to select patients with a first unprovoked venous thromboembolism who can stop anticoagulant therapy: a cohort study. Annals of internal medicine, 162(1), 27-34.

Lindhoff-Last, E., Ansell, J., Spiro, T., & Samama, M. M. (2013). Laboratory testing of rivaroxaban in routine clinical practice: when, how, and which assays. Annals of medicine, 45(5-6), 423-429.

Linkins, L. A., Bates, S. M., Lang, E., Kahn, S. R., Douketis, J. D., Julian, J., ... & Lee, A. Y. (2013). Selective D-dimer testing for diagnosis of a first suspected episode of deep venous thrombosis: a randomized trial. Annals of internal medicine, 158(2), 93-100.

Lip, G. Y., Keshishian, A., Kamble, S., Pan, X., Mardekian, J., Horblyuk, R., & Hamilton, M. (2016). Real-world comparison of major bleeding risk among non-valvular atrial fibrillation patients initiated on apixaban, dabigatran, rivaroxaban, or warfarin. Thrombosis and haemostasis, 115(05), 975-986.

Long, A., Zhang, L., Zhang, Y., Jiang, B., Mao, Z., Li, H., ... & Tang, P. (2014). Efficacy and safety of rivaroxaban versus low-molecular-weight heparin therapy in patients with lower limb fractures. Journal of thrombosis and thrombolysis, 38(3), 299-305.

Mueck, W., Stampfuss, J., Kubitza, D., & Becka, M....