- Email: [email protected]
Unilateral Lower Leg Edema and Dyspnea in a Female Patient
CASE CHALLENGE
Unilateral Lower Leg Edema and Dyspnea in a Female Patient Myriam Jean Cadet, PhD, FNP-C ABSTRACT This is a case study describing a 48-year-old woman complaining of unilateral lower leg edema and dyspnea. Understanding the complexities of these symptoms can help the nurse practitioner to make timely decisions to save a life. Keywords: DVT, PE, unilateral lower leg edema Ó 2017 Elsevier Inc. All rights reserved.
L
eg edema and dyspnea often occur with other pathologic conditions.1,2 The challenge for outpatient and hospital-based nurse practitioners is to correctly recognize the constellation of symptoms to identify the underlying etiology for an accurate diagnosis and treatment. Often, the symptom of swelling of the lower extremities accompanied by dyspnea can be misattributed to separate etiologies; thus, the most critical clinical pathology is missed or misdiagnosed. This case report highlights a patient’s chief complaint of unilateral lower leg edema and dyspnea, a complete history of the present illness, clinical reasoning for differential diagnoses, and diagnostic tests. Results of the tests, diagnosis, and treatment plan will be presented.
CASE PRESENTATION Chief Complaint
A 48-year-old female patient, gravida 6, para 3, and abortus 3, arrived at the emergency department with a complaint of swelling and pain in the right lower leg. She reported difficulty in walking with shortness of breath (SOB) and palpitations. These symptoms started 4 days earlier. History of Present Illness
The patient reported a progressive increase in episodic SOB for the past few days. She stated, “I cannot catch my breath when I walk.” The pain in her right lower leg abates when not walking.
and anemia. Her past surgical history includes a fracture of the left arm 2 years ago. The patient has not traveled outside of the United States recently. Her immunizations are up-to-date. Medications
Her medications include over-the-counter Centrum; Pfizer Inc, Kings Mountain, NC daily and Tylenol (acetaminophen), McNeil-PPC, Inc., PA 1,000 mg by mouth as needed for pain. She denies any allergies. FAMILY HISTORY
The patient’s family history is significant for hypertension, diabetes mellitus, and coronary artery disease. Her mother died at 65 years of age from a heart attack 2 years ago secondary to coronary artery disease. Her father is 72 years old and has diabetes. Both of her sisters have diabetes mellitus and hypertension. The patient is of African descent. PERSONAL AND SOCIAL HISTORY
She smoked one-half pack of cigarettes every week for 15 years but stopped smoking last year. She denies any alcohol or recreational drug abuse. She usually socializes with coworkers and friends. She was married for 15 years and divorced last year. She plans to lose weight because she is obese but has a lack of motivation to exercise. She works as a clerk in a hospital at night. REVIEW OF SYMPTOMS
Past Medical History
Her medical history includes uterine leiomyoma, dysmenorrhea, heavy menstrual bleeding, obesity, www.npjournal.org
Beyond the chief complaint and history of the present illness, the patient denies any loss of sensation, tingling, or numbness of the lower extremities. The Journal for Nurse Practitioners - JNP
e1
PERTINENT PHYSICAL EXAMINATION FINDINGS
The patient’s physical examination findings are as follows: 1. Vital signs: blood pressure of 146/97mm Hg, pulse of 103 beats/min and irregular, respiration rate of 22 breaths/min, temperature of 98.2 F, and oxygen saturation of 92% to 94% on room air and 94% to 96% on a 2-L nasal cannula; pain in the right leg rated at 6 on a pain scale; and weight of 222 lb with a body mass index of 40 2. Neurology: alert and oriented 3, cooperative with no distress, and speech clear and coherent 3. Respiratory: tachypnea with shallow breathing and dyspnea on exertion 4. Cardiovascular: rate 103 beats/min, heart sounds normal with no murmurs; denies chest pain; bilateral right and left carotid, brachial, and radial pulses are þ2; and left femoral, posterior tibial, and popliteal pulses are þ1, but pulses are absent on the right side 5. Abdomen: distended, a solid mass is palpated; normal bowel sounds in all quadrants; and no liver enlargement or aortic bruits
e2
The Journal for Nurse Practitioners - JNP
6. Genitourinary: a bimanual pelvic examination reveals a smooth, moveable, nontender and firm mass, the enlarged uterus is palpable and felt above the pubic bone (equivalent to 12 weeks pregnant), and the uterus position is anteverted 7. Musculoskeletal: right lower leg has pitting edema (þ2), tender, swollen, painful, and skin temperature warm to touch, but the left lower leg is normal CASE STUDY QUESTIONS
1. Based on the patient’s chief complaint, history of present illness, and physical examination, what are the differential diagnoses? 2. What would be the most appropriate initial laboratory, screening tool, and diagnostic imaging tests to order? 3. What is the most likely diagnosis to be considered? 4. Based on the confirmed diagnosis, what would be the most appropriate initial treatment for this patient? If you believe you know the answers to the following questions questions, then test yourself and refer to page XXX for the answers.
Volume
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CASE CHALLENGE
Unilateral Lower Leg Edema and Dyspnea in a Female Patient (continued from page xxx) CASE STUDY QUESTIONS WITH ANSWERS 1. Based on the Patient’s Chief Complaint, History of Present Illness, and Physical Examination, What Are the Differential Diagnoses?
T
he differential diagnoses are deep vein thrombosis (DVT), cellulitis, pulmonary embolism (PE), pneumonia, congestive heart failure (CHF), and anemia.1 Localized unilateral leg swelling may be the result of compression of the lymphatic or venous drainage systems such as DVT or cellulitis. Cardiac causes of progressive dyspnea on exertion include CHF. However, CHF is a chronic systemic condition, and a patient usually presents with bilateral and generalized edema of the lower extremities. Furthermore, a case presentation of dyspnea may be caused by pulmonary disease or other conditions such as PE, pneumonia, or anemia.
2. What Would Be the Most Appropriate Initial Laboratory, Screening Tool, and Diagnostic Imaging Tests to Order?
Complete Blood Count. The patient did not have any previous laboratory results available; therefore, a complete blood count was drawn. Results from the complete blood count revealed a low red blood cell count 4.1 million cells per microliter (cells/mcL), a low mean corpuscular volume (70 femtoliter), a low mean corpuscular hemoglobin level (25.5 pg), a low hemoglobin concentration (11 g/dL), a low hematocrit concentration (29%), a low ferritin level (4.0 ng/dL), and a normal platelet count. These findings suggest microcytic hypochromic anemia (iron deficiency anemia) likely caused by chronic blood loss from menstruation. D-dimer Assay and B-type Natriuretic Peptide. A D-dimer assay is a screening test for venous thromboembolism (VTE). The result of the assay for this patient was elevated (0.92 mg/mL, normal value 0.72). A D-dimer assay has a high sensitivity but a low specificity, which does not rule out DVT. Also, the B-type natriuretic peptide level result was normal (< 89 pg/mL). It is a screening test www.npjournal.org
for CHF. However, if the B-type natriuretic peptide level was > 500 pg/mL, the dyspnea may likely have been caused by CHF. Wells’ Model. The clinical practice guidelines from the American College of Chest Physicians recommend a validated clinical prediction rule, such as the Wells’ model, to estimate the pretest probability for PE and DVT (https://www.mdcalc.com/ wells-criteria-dvt). A low score ( 4) indicates a negative test result, excluding PE. However, a score of > 4 indicates PE is likely. The results from the Wells’ model revealed a total criteria point count of 4.5 for this patient, indicating moderate probability for PE and DVT. The risk score interpretation identified in the Wells’ model is high (score > 6), intermediate or moderate (score > 2 and < 6), and low (score < 2) probability. The Wells’ model alone is not enough to diagnose PE; additional diagnostic tests imaging are needed. Chest X-ray. A chest X-ray was ordered to rule out a diagnosis of CHF or pneumonia. The results of the chest X-ray showed an anterior-posterior view of no respiratory conditions, ascites, or chest diseases. The lungs were clear with no pleural abnormality. The mediastinum and the heart appeared normal. CHF and pneumonia were ruled out as diagnoses because the chest X-ray showed no evidence of bilateral pleural effusions or infiltrates. Echocardiography. Echocardiography was ordered to evaluate ventricular hypertrophy associated with CHF. The results of the echocardiogram revealed a left ventricular ejection fraction of 60% to 65% and no evidence of right ventricular dilation, hypertrophy, or right-sided filling pressure for CHF. Electrocardiogram and Arterial Blood Gas. An electrocardiogram was performed to rule out cardiac diseases such as CHF. The results did not show ischemia, ST- or T-wave changes, or arrhythmia. The electrocardiogram revealed sinus tachycardia. Also, the arterial blood gas results showed hypoxia and hypocapnia, which were suggestive of PE. However, these results are not diagnostic for PE. The Journal for Nurse Practitioners - JNP
e1
Pelvic (Transabdominal) Ultrasonography. A pelvic (transabdominal) ultrasound was ordered to establish a diagnosis of uterine leiomyoma. It is an initial imaging modality for uterine leiomyoma because of the ease of use, availability, and cost-effectiveness. Also, a large myoma can occlude the blood flow into the pelvic veins, which can put the patient at increased risk of developing thrombus formation.2 The results of pelvic ultrasonography disclosed that the uterus was anteverted and measured approximately 15 cm in length 10 cm anterior posterior 11 cm transverse. Also, the enlarged uterus contained multiple leiomyomas including intracavitary lesions. Computed Tomographic Venography and Pulmonary Angiography. These studies were ordered for this patient to investigate and diagnose DVT and PE. Computed tomographic venography of the lower legs showed a right common femoral venous thrombus. Computed tomographic pulmonary angiography revealed multiple segmental and subsegmental occlusive pulmonary emboli. Computed tomographic venography and computed tomographic pulmonary angiography are usually combined using only 1 intravenous injection of contrast dye and are now advocated as a single procedure for the diagnosis of PE and DVT. 3. What Is the Most Likely Diagnosis to Be Considered?
The most likely diagnosis for this patient is VTE. VTE is manifested by DVT and PE secondary to compression of the femoral vein by the leiomyoma. This patient’s clinical presentation and physical examination findings were highly suspicious for VTE. Thus, the use of a validated clinical prediction rule, such as the Well’s model, was supported and is a critical aspect of guiding the diagnostic evaluation. 4. Based on the Confirmed Diagnoses, What Would Be the Most Appropriate Initial Treatment for This Patient?
For patients presenting with VTE without any cancer, the American College of Chest Physicians guidelines recommend long-term anticoagulant therapy treatments such as dabigatran, rivaroxaban, apixaban, or edoxaban over low-molecular-weight heparin (LMWH) and vitamin K antagonist (VKA).3 In VTE patients treated with anticoagulants, the e2
The Journal for Nurse Practitioners - JNP
guidelines from the American College of Chest Physicians do not recommend the use of an inferior vena cava filter.3 Additionally, for patients with DVT, prescribing compression stockings routinely to prevent postthrombotic syndrome is not recommended. In patients with a low risk of recurrent VTE, subsegmental PE, and no proximal DVT, the guidelines recommend clinical surveillance over anticoagulation therapy.3 However, if the risk of VTE with subsegmental PE is higher, the use of anticoagulant therapy treatment is recommended over clinical surveillance.3 The patient was found to have subsegmental PE with a high-risk probability of VTE. She was treated with the LMWH Lovenox (enoxaparin); Sanofiaventis U.S. LLC, Bridgewater, NJ 1.5 mg/kg daily subcutaneously as well as with warfarin VKA 5 mg by mouth with a targeting international normalized ratio of 2.5 (normal range is 2.0-3.0) prescribed for VTE for 3 months. Before discharge home, aspirin therapy was prescribed as an extended treatment because of no contraindication of use to prevent recurrent VTE.4 After the patient’s clinical situation is stabilized, then consideration for surgical treatment of the leiomyomas is critical. It would be prudent to treat and prevent further recurrences and complications of thrombosis as well as heavy menses with subsequent iron deficiency anemia because of menstrual blood loss. Medical therapy can reduce heavy menstruation in patients with leiomyomas. However, the patient has a compressive disorder because of the enlarged uterus; therefore, she was not a candidate for medical therapy. Surgery is her best option. Surgical interventions include hysterectomy, myomectomy, or uterine embolization, which can reduce symptoms to a manageable state or even cure leiomyomas.5 The patient was referred for possible leiomyoma surgery. CONCLUSION
The patient had a history of uterine leiomyomas and developed complications of VTE (DVT and PE); she was admitted to the emergency room for further observation. Prompt recognition of VTE is important, and it requires effective assessment, management, and evaluation for safe care delivery. The patient presented with SOB, right lower leg swelling, tenderness, and pain, which are signs and Volume
-,
Issue
-, -/-
2017
symptoms of DVT and PE. The Wells’ model was implemented as a validated clinical screening tool to identify her risk for VTE. Her diagnostic imaging tests confirmed she had DVT and PE. She was treated with therapeutic anticoagulants such as LMWH and VKA. She was admitted to the intensive care unit for additional management of care. Later, she was discharged home and referred to gynecology in an outpatient setting to plan for uterine leiomyoma surgery. Nurse practitioners need to understand the complexities of presenting patient complaints with VTE and the necessity to perform comprehensive health histories with thorough physical examinations. It is also important to be cognizant of and use validated screening tools to assess the clinical pretest probability for thrombosis, which will guide the appropriate diagnostic imaging studies to rule out PE and DVT to save a life.
www.npjournal.org
References 1. Lowry D, Kay MD, Tiwari A. Common femoral vein canal lipoma causing chronic unilateral lower limb swelling. BMJ Case Rep. 2014;2014; bcr2013201968. 2. Khademvatani K, Rezaei Y, Kerachian A, Seyyed-Mohammadzad MH, Eskandari R, Rostamzadeh A. Acute pulmonary embolism caused by enlarged uterine leiomyoma: a rare presentation. Am J Case Rep. 2014;15:300-303. https://doi.org/10.12659/AJCR.890607. 3. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and Expert Panel report. Chest. 2016;149(2):315-352. https:// doi.org/10.1016/j.chest.2015.11.026. 4. Streiff MB, Agnelli G, Connors JM, et al. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis. 2016;41(1):32-67. 5. De La Cruz MS, Buchanan EM. Uterine fibroids: diagnosis and treatment. Am Fam Physician. 2017;95(2):100-107.
Myriam J. Cadet, PhD, FNP-C, is an adjunct assistant professor at Lehman College in Bronx, NY, and can be reached at [email protected]. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2017.10.006
The Journal for Nurse Practitioners - JNP
e3
Unilateral Lower Leg Edema and Dyspnea in a Female Patient Myriam Jean Cadet, PhD, FNP-C ABSTRACT This is a case study describing a 48-year-old woman complaining of unilateral lower leg edema and dyspnea. Understanding the complexities of these symptoms can help the nurse practitioner to make timely decisions to save a life. Keywords: DVT, PE, unilateral lower leg edema Ó 2017 Elsevier Inc. All rights reserved.
L
eg edema and dyspnea often occur with other pathologic conditions.1,2 The challenge for outpatient and hospital-based nurse practitioners is to correctly recognize the constellation of symptoms to identify the underlying etiology for an accurate diagnosis and treatment. Often, the symptom of swelling of the lower extremities accompanied by dyspnea can be misattributed to separate etiologies; thus, the most critical clinical pathology is missed or misdiagnosed. This case report highlights a patient’s chief complaint of unilateral lower leg edema and dyspnea, a complete history of the present illness, clinical reasoning for differential diagnoses, and diagnostic tests. Results of the tests, diagnosis, and treatment plan will be presented.
CASE PRESENTATION Chief Complaint
A 48-year-old female patient, gravida 6, para 3, and abortus 3, arrived at the emergency department with a complaint of swelling and pain in the right lower leg. She reported difficulty in walking with shortness of breath (SOB) and palpitations. These symptoms started 4 days earlier. History of Present Illness
The patient reported a progressive increase in episodic SOB for the past few days. She stated, “I cannot catch my breath when I walk.” The pain in her right lower leg abates when not walking.
and anemia. Her past surgical history includes a fracture of the left arm 2 years ago. The patient has not traveled outside of the United States recently. Her immunizations are up-to-date. Medications
Her medications include over-the-counter Centrum; Pfizer Inc, Kings Mountain, NC daily and Tylenol (acetaminophen), McNeil-PPC, Inc., PA 1,000 mg by mouth as needed for pain. She denies any allergies. FAMILY HISTORY
The patient’s family history is significant for hypertension, diabetes mellitus, and coronary artery disease. Her mother died at 65 years of age from a heart attack 2 years ago secondary to coronary artery disease. Her father is 72 years old and has diabetes. Both of her sisters have diabetes mellitus and hypertension. The patient is of African descent. PERSONAL AND SOCIAL HISTORY
She smoked one-half pack of cigarettes every week for 15 years but stopped smoking last year. She denies any alcohol or recreational drug abuse. She usually socializes with coworkers and friends. She was married for 15 years and divorced last year. She plans to lose weight because she is obese but has a lack of motivation to exercise. She works as a clerk in a hospital at night. REVIEW OF SYMPTOMS
Past Medical History
Her medical history includes uterine leiomyoma, dysmenorrhea, heavy menstrual bleeding, obesity, www.npjournal.org
Beyond the chief complaint and history of the present illness, the patient denies any loss of sensation, tingling, or numbness of the lower extremities. The Journal for Nurse Practitioners - JNP
e1
PERTINENT PHYSICAL EXAMINATION FINDINGS
The patient’s physical examination findings are as follows: 1. Vital signs: blood pressure of 146/97mm Hg, pulse of 103 beats/min and irregular, respiration rate of 22 breaths/min, temperature of 98.2 F, and oxygen saturation of 92% to 94% on room air and 94% to 96% on a 2-L nasal cannula; pain in the right leg rated at 6 on a pain scale; and weight of 222 lb with a body mass index of 40 2. Neurology: alert and oriented 3, cooperative with no distress, and speech clear and coherent 3. Respiratory: tachypnea with shallow breathing and dyspnea on exertion 4. Cardiovascular: rate 103 beats/min, heart sounds normal with no murmurs; denies chest pain; bilateral right and left carotid, brachial, and radial pulses are þ2; and left femoral, posterior tibial, and popliteal pulses are þ1, but pulses are absent on the right side 5. Abdomen: distended, a solid mass is palpated; normal bowel sounds in all quadrants; and no liver enlargement or aortic bruits
e2
The Journal for Nurse Practitioners - JNP
6. Genitourinary: a bimanual pelvic examination reveals a smooth, moveable, nontender and firm mass, the enlarged uterus is palpable and felt above the pubic bone (equivalent to 12 weeks pregnant), and the uterus position is anteverted 7. Musculoskeletal: right lower leg has pitting edema (þ2), tender, swollen, painful, and skin temperature warm to touch, but the left lower leg is normal CASE STUDY QUESTIONS
1. Based on the patient’s chief complaint, history of present illness, and physical examination, what are the differential diagnoses? 2. What would be the most appropriate initial laboratory, screening tool, and diagnostic imaging tests to order? 3. What is the most likely diagnosis to be considered? 4. Based on the confirmed diagnosis, what would be the most appropriate initial treatment for this patient? If you believe you know the answers to the following questions questions, then test yourself and refer to page XXX for the answers.
Volume
-,
Issue
-, -/-
2017
CASE CHALLENGE
Unilateral Lower Leg Edema and Dyspnea in a Female Patient (continued from page xxx) CASE STUDY QUESTIONS WITH ANSWERS 1. Based on the Patient’s Chief Complaint, History of Present Illness, and Physical Examination, What Are the Differential Diagnoses?
T
he differential diagnoses are deep vein thrombosis (DVT), cellulitis, pulmonary embolism (PE), pneumonia, congestive heart failure (CHF), and anemia.1 Localized unilateral leg swelling may be the result of compression of the lymphatic or venous drainage systems such as DVT or cellulitis. Cardiac causes of progressive dyspnea on exertion include CHF. However, CHF is a chronic systemic condition, and a patient usually presents with bilateral and generalized edema of the lower extremities. Furthermore, a case presentation of dyspnea may be caused by pulmonary disease or other conditions such as PE, pneumonia, or anemia.
2. What Would Be the Most Appropriate Initial Laboratory, Screening Tool, and Diagnostic Imaging Tests to Order?
Complete Blood Count. The patient did not have any previous laboratory results available; therefore, a complete blood count was drawn. Results from the complete blood count revealed a low red blood cell count 4.1 million cells per microliter (cells/mcL), a low mean corpuscular volume (70 femtoliter), a low mean corpuscular hemoglobin level (25.5 pg), a low hemoglobin concentration (11 g/dL), a low hematocrit concentration (29%), a low ferritin level (4.0 ng/dL), and a normal platelet count. These findings suggest microcytic hypochromic anemia (iron deficiency anemia) likely caused by chronic blood loss from menstruation. D-dimer Assay and B-type Natriuretic Peptide. A D-dimer assay is a screening test for venous thromboembolism (VTE). The result of the assay for this patient was elevated (0.92 mg/mL, normal value 0.72). A D-dimer assay has a high sensitivity but a low specificity, which does not rule out DVT. Also, the B-type natriuretic peptide level result was normal (< 89 pg/mL). It is a screening test www.npjournal.org
for CHF. However, if the B-type natriuretic peptide level was > 500 pg/mL, the dyspnea may likely have been caused by CHF. Wells’ Model. The clinical practice guidelines from the American College of Chest Physicians recommend a validated clinical prediction rule, such as the Wells’ model, to estimate the pretest probability for PE and DVT (https://www.mdcalc.com/ wells-criteria-dvt). A low score ( 4) indicates a negative test result, excluding PE. However, a score of > 4 indicates PE is likely. The results from the Wells’ model revealed a total criteria point count of 4.5 for this patient, indicating moderate probability for PE and DVT. The risk score interpretation identified in the Wells’ model is high (score > 6), intermediate or moderate (score > 2 and < 6), and low (score < 2) probability. The Wells’ model alone is not enough to diagnose PE; additional diagnostic tests imaging are needed. Chest X-ray. A chest X-ray was ordered to rule out a diagnosis of CHF or pneumonia. The results of the chest X-ray showed an anterior-posterior view of no respiratory conditions, ascites, or chest diseases. The lungs were clear with no pleural abnormality. The mediastinum and the heart appeared normal. CHF and pneumonia were ruled out as diagnoses because the chest X-ray showed no evidence of bilateral pleural effusions or infiltrates. Echocardiography. Echocardiography was ordered to evaluate ventricular hypertrophy associated with CHF. The results of the echocardiogram revealed a left ventricular ejection fraction of 60% to 65% and no evidence of right ventricular dilation, hypertrophy, or right-sided filling pressure for CHF. Electrocardiogram and Arterial Blood Gas. An electrocardiogram was performed to rule out cardiac diseases such as CHF. The results did not show ischemia, ST- or T-wave changes, or arrhythmia. The electrocardiogram revealed sinus tachycardia. Also, the arterial blood gas results showed hypoxia and hypocapnia, which were suggestive of PE. However, these results are not diagnostic for PE. The Journal for Nurse Practitioners - JNP
e1
Pelvic (Transabdominal) Ultrasonography. A pelvic (transabdominal) ultrasound was ordered to establish a diagnosis of uterine leiomyoma. It is an initial imaging modality for uterine leiomyoma because of the ease of use, availability, and cost-effectiveness. Also, a large myoma can occlude the blood flow into the pelvic veins, which can put the patient at increased risk of developing thrombus formation.2 The results of pelvic ultrasonography disclosed that the uterus was anteverted and measured approximately 15 cm in length 10 cm anterior posterior 11 cm transverse. Also, the enlarged uterus contained multiple leiomyomas including intracavitary lesions. Computed Tomographic Venography and Pulmonary Angiography. These studies were ordered for this patient to investigate and diagnose DVT and PE. Computed tomographic venography of the lower legs showed a right common femoral venous thrombus. Computed tomographic pulmonary angiography revealed multiple segmental and subsegmental occlusive pulmonary emboli. Computed tomographic venography and computed tomographic pulmonary angiography are usually combined using only 1 intravenous injection of contrast dye and are now advocated as a single procedure for the diagnosis of PE and DVT. 3. What Is the Most Likely Diagnosis to Be Considered?
The most likely diagnosis for this patient is VTE. VTE is manifested by DVT and PE secondary to compression of the femoral vein by the leiomyoma. This patient’s clinical presentation and physical examination findings were highly suspicious for VTE. Thus, the use of a validated clinical prediction rule, such as the Well’s model, was supported and is a critical aspect of guiding the diagnostic evaluation. 4. Based on the Confirmed Diagnoses, What Would Be the Most Appropriate Initial Treatment for This Patient?
For patients presenting with VTE without any cancer, the American College of Chest Physicians guidelines recommend long-term anticoagulant therapy treatments such as dabigatran, rivaroxaban, apixaban, or edoxaban over low-molecular-weight heparin (LMWH) and vitamin K antagonist (VKA).3 In VTE patients treated with anticoagulants, the e2
The Journal for Nurse Practitioners - JNP
guidelines from the American College of Chest Physicians do not recommend the use of an inferior vena cava filter.3 Additionally, for patients with DVT, prescribing compression stockings routinely to prevent postthrombotic syndrome is not recommended. In patients with a low risk of recurrent VTE, subsegmental PE, and no proximal DVT, the guidelines recommend clinical surveillance over anticoagulation therapy.3 However, if the risk of VTE with subsegmental PE is higher, the use of anticoagulant therapy treatment is recommended over clinical surveillance.3 The patient was found to have subsegmental PE with a high-risk probability of VTE. She was treated with the LMWH Lovenox (enoxaparin); Sanofiaventis U.S. LLC, Bridgewater, NJ 1.5 mg/kg daily subcutaneously as well as with warfarin VKA 5 mg by mouth with a targeting international normalized ratio of 2.5 (normal range is 2.0-3.0) prescribed for VTE for 3 months. Before discharge home, aspirin therapy was prescribed as an extended treatment because of no contraindication of use to prevent recurrent VTE.4 After the patient’s clinical situation is stabilized, then consideration for surgical treatment of the leiomyomas is critical. It would be prudent to treat and prevent further recurrences and complications of thrombosis as well as heavy menses with subsequent iron deficiency anemia because of menstrual blood loss. Medical therapy can reduce heavy menstruation in patients with leiomyomas. However, the patient has a compressive disorder because of the enlarged uterus; therefore, she was not a candidate for medical therapy. Surgery is her best option. Surgical interventions include hysterectomy, myomectomy, or uterine embolization, which can reduce symptoms to a manageable state or even cure leiomyomas.5 The patient was referred for possible leiomyoma surgery. CONCLUSION
The patient had a history of uterine leiomyomas and developed complications of VTE (DVT and PE); she was admitted to the emergency room for further observation. Prompt recognition of VTE is important, and it requires effective assessment, management, and evaluation for safe care delivery. The patient presented with SOB, right lower leg swelling, tenderness, and pain, which are signs and Volume
-,
Issue
-, -/-
2017
symptoms of DVT and PE. The Wells’ model was implemented as a validated clinical screening tool to identify her risk for VTE. Her diagnostic imaging tests confirmed she had DVT and PE. She was treated with therapeutic anticoagulants such as LMWH and VKA. She was admitted to the intensive care unit for additional management of care. Later, she was discharged home and referred to gynecology in an outpatient setting to plan for uterine leiomyoma surgery. Nurse practitioners need to understand the complexities of presenting patient complaints with VTE and the necessity to perform comprehensive health histories with thorough physical examinations. It is also important to be cognizant of and use validated screening tools to assess the clinical pretest probability for thrombosis, which will guide the appropriate diagnostic imaging studies to rule out PE and DVT to save a life.
www.npjournal.org
References 1. Lowry D, Kay MD, Tiwari A. Common femoral vein canal lipoma causing chronic unilateral lower limb swelling. BMJ Case Rep. 2014;2014; bcr2013201968. 2. Khademvatani K, Rezaei Y, Kerachian A, Seyyed-Mohammadzad MH, Eskandari R, Rostamzadeh A. Acute pulmonary embolism caused by enlarged uterine leiomyoma: a rare presentation. Am J Case Rep. 2014;15:300-303. https://doi.org/10.12659/AJCR.890607. 3. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and Expert Panel report. Chest. 2016;149(2):315-352. https:// doi.org/10.1016/j.chest.2015.11.026. 4. Streiff MB, Agnelli G, Connors JM, et al. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis. 2016;41(1):32-67. 5. De La Cruz MS, Buchanan EM. Uterine fibroids: diagnosis and treatment. Am Fam Physician. 2017;95(2):100-107.
Myriam J. Cadet, PhD, FNP-C, is an adjunct assistant professor at Lehman College in Bronx, NY, and can be reached at [email protected]. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2017.10.006
The Journal for Nurse Practitioners - JNP
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