week 6 discussion

Description

1a) Identify two (2) additional questions that were not asked in the case study and should have been?

1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.

DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.

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12/26/23, 10:16 PM
Rubric Assessment – NSG6020_A-Advanced Health & Physical Assessment CP03 – South University
SUO Discussion Rubric (40 Points) – Version 1.2
Course: NSG6020_A-Advanced Health & Physical Assessment CP03
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exists to evaluate.
provided is
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understanding of the
understanding of the
depth, well thought-
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topic(s) covered. A
topic(s) covered. A
out understanding
and/or does not
basic understanding
good understanding
of the topic(s)
answer the
is when you are able
is when you are able
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this basic
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understanding of the
understanding,
sincere reflection
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topic and/or
initial posting may
and addresses most
course/assigned
inadequate
not include
aspects of the
readings.
preparation.
complete
assignment,
development of all
although all
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concepts may not be
assignment.
fully developed.
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Discussion
Rubric Assessment – NSG6020_A-Advanced Health & Physical Assessment CP03 – South University
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Proficient (B: 9)
9 points
Exemplary (A: 10)
10 points
Criterion Score
No responses to
May include one or
Comments to two or
Comments to two or
Comments to two or
/ 10
other classmates
more of the
more classmates’
more classmates’
more classmates’
were posted in this
following:
initial posts but only
initial posts on more
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discussion forum.
*Comments to only
on one day of the
than one day.
the instructor’s
one other student’s
week. Comments
Comments are
comment (if
post.
are substantive,
substantive,
applicable) on two or
*Comments are not
meaning they reflect
meaning they reflect
more days.
substantive, such as
and expand on what
and expand on what
Responses
just one line or
the other student
the other student
demonstrate an
saying, “Good job”
wrote.
wrote.
analysis of peers’
or “I agree.
comments, building
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on previous posts.
topic.
Comments extend
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meaningful
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Writing
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Citation Style)
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8 points
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10 points
Criterion Score
No postings for
Numerous issues in
Some spelling,
Minor errors in
Minor to no errors
/ 10
which to evaluate
any of the following:
grammatical, and/or
grammar, mechanics,
exist in grammar,
language and
grammar, mechanics,
structural errors are
or spelling in the
mechanics, or
grammar exist.
spelling, use of
present. Some errors
initial posting are
spelling in both the
slang, and
in formatting
present. Minor
initial post and
incomplete or
citations and
errors in formatting
comments to others.
missing citations and
references are
citations and
Formatting of
references. If
present. If required
references may
citations and
required for the
for the assignment,
exist. If required for
references is correct.
assignment, did not
utilizes sources to
the assignment,
If required for the
use course, text,
support work for
utilizes sources to
assignment, utilizes
and/or outside
initial post but not
support work for
sources to support
readings (where
comments to other
both the initial post
work for both the
relevant) to support
students. Sources
and some of the
initial post and the
work.
include course/text
comments to other
comments to other
readings but outside
students. Sources
students. Sources
sources (when
include course and
include course and
relevant) include
text readings as well
text readings as well
non-
as outside sources
as outside sources
academic/authoritati
(when relevant) that
(when relevant) that
ve, such as Wikis
are academic and
are academic and
and .com resources.
authoritative (e.g.,
authoritative (e.g.,
journal articles,
journal articles,
other text books,
other text books,
.gov Web sites,
.gov Web sites,
professional
professional
organization Web
organization Web
sites, cases, statutes,
sites, cases, statutes,
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Writing
Rubric Assessment – NSG6020_A-Advanced Health & Physical Assessment CP03 – South University
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Satisfaction (C: 7-8)
8 points
Proficient (B: 9)
9 points
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or administrative
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rules).
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Proficient (B Range)
0 points
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There was no
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1 point minimum
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been met on the competencies
for this assignment.
28 points minimum
Satisfactory progress has been
achieved on the competencies
for this assignment.
32 points minimum
Proficiency has been
achieved on the
competencies for this
assignment.
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Range)
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The competencies for
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been mastered.
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Family Medicine 07: 53-year-old male with leg swelling
User: ARIADNA ZARZUELA
Email: [email protected]
Date: December 26, 2023 10:34 PM
Learning Objectives
The student should be able to:
Describe the timing of initial management for common and “don’t miss” etiologies of leg swelling
Discuss the value of a team-based approach to chronic disease management.
Discuss the impact of smoking, hypertension, diabetes and obesity on health and mortality.
Elicit focused history that includes information about adherence, self-management and barriers to care.
Establish a focused history and physical examination using evidence-based criteria to distinguish common vs. “don’t miss” diagnoses of leg
swelling.
Apply commonly used classification system for grading severity of diabetic ulcers.
Describe the initial management of DVT including goals of treatment, setting, and monitoring.
Describe the initial management of diabetic foot ulcers.
Discuss long term treatment options of DVT after stabilization.
Discuss who should be screening for inherited thrombophilia.
Describe the role of the family physician in coordinating comprehensive, multidisciplinary care of patients presenting with unilateral lower extremity
edema.
Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with lower
extremity edema.
Propose a cost-effective diagnostic workup for a patient presenting with leg swelling.
Describe an evidence based plan for appropriate screening, assessment of risk and counseling on wellness and risk reduction.
Summarize the key features of a patient presenting with unilateral lower extremity edema, capturing the information essential for differentiating
between the common and “don’t miss” etiologies.
Propose a cost-effective diagnostic workup for a patient presenting with a foot ulcer.
Describe the initial management of common diagnoses that present with foot ulcers.
Describe the initial management of common diagnoses that present with Deep vein thrombosis.
Describe the initial management of thrombotic disease with inherited thrombophilia.
Propose a cost-effective diagnostic work-up for a patient presenting with possible thrombophila.
Knowledge
Predictive Value of Diagnostic Tests
Sensitivity is the proportion of patients with disease who test positive.
Sensitivity = True Positives/True Positives PLUS False Negatives
Specificity is the proportion of patients without disease who test negative.
Specificity = True Negatives/True negatives Plus False Positives
Positive Predictive Value is the probability the person with a positive test result actually has the disease being tested for.
PPV = True Positives/True Positives +False Positives
Negative Predictive Value is the probability the person with a negative test result does not have the disease being tested for.
NPV = True Negative/False Negative +True Negative
Sample 2X2 table. Test sensitivity is 98%. Test specificity is 95%. Prevalence of disease is 1 in 100. 10,000 people are screened with the test.
disease no disease
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test + 98
492
test – 2
9408
The positive predictive value (PPV) is 98/(98+492) = 16.6%. Even though the screening test has a sensitivity of 98%, a patient with a positive test
result in this low prevalence population has only a 16.6% chance of having the disease.
Some commonly used screening tests have poorer test characteristics than this example. For example, PSA for prostate cancer screening has the
following test characteristics, depending upon the cutoff for a positive test:
Cut-off 3.1 ng/mL; sensitivity 32.2% and specificity 86.7%
Cut-off 1.1 ng/mL; sensitivity 83.4% and specificity 38.9%
It is important to understand the characteristics of studies you order to better interpret what the results really mean.
Prevention of Embolism
More than 95% of pulmonary emboli arise from thrombi in the deep venous system of the lower extremities. Ninety percent of deaths due to
pulmonary embolism result within an hour or two—before diagnostic and therapeutic plans can be implemented. Therefore, prevention and prompt
treatment of DVT is the most effective approach to prevent embolism and death due to PE.
Parenteral Agents
There are three parenteral therapies used to either bridge with warfarin or pretreat prior to initiation of dabigatran: unfractionated heparin, lowmolecular weight heparin (LMWH), and fondaparinux.
Pharmacology and Management of the Vitamin K Antagonists
Pharmacology and Management of the Vitamin K Antagonists
The half-life of warfarin is around 40 hours, which means it will take five to seven days for the steady-state to be stable. When making a dose
adjustment for an outpatient on warfarin, one should wait at least this long before rechecking an INR, as checking sooner can lead to overreactions
and great swings in a patient’s INR. If the goal INR is substantially overshot, it increases the risk of bleeding complications significantly.
Clinical Skills
Ulcer Classification: The Wagner Grading System
The Wagner Grading System
1. Grade 1: Diabetic ulcer (superficial)
2. Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
3. Grade 3: Deep ulcer with abscess or osteomyelitis
4. Grade 4: Gangrene forefoot (partial)
5. Grade 5: Extensive gangrene of foot
Images for the corresponding ulcer classifications.
Family Physicians Coordinate Comprehensive Multidisciplinary Care
Family medicine physicians play an essential role in optimizing patient care by coordinating comprehensive multidisciplinary care.
Management
Ulcer Management
Grade 1 and 2 ulcer management generally can be done as outpatient and should include extensive debridement, local wound care, and
relief of pressure. If there is significant erythema and/or purulent exudate, then treatment for infection is warranted.
Grade 3 lesions require evaluation for possible osteomyelitis as well as peripheral artery disease. Both of these conditions may need to be
addressed prior to the resolution of the ulcer. Typically at least a brief hospitalization is required to address these issues.
Grade 4 and Grade 5 lesions require emergent hospitalization and surgical consultation, often resulting in amputation.
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Goals of DVT Therapy
1. Immediate inhibition of the growth of thromboemboli and prevention of pulmonary embolism
2. Promotion of thromboembolic resolution
3. Prevention of recurrence
The day-to-day risk of the development of a pulmonary embolism (PE) is high in patients with acute DVT, so immediate anticoagulation is necessary.
It is important to choose an anticoagulant that will act immediately to prevent any further clot formation.
* Image Credit to ASH 2020 Guidelines
Acute Management of DVT
Therapeutic strategies for initiating anticoagulation in a patient with an acute DVT:
Oral Monotherapy with certain Direct Oral Anticoagulants (DOAC)
Two of the oral factor Xa inhibitors (rivaroxaban and apixaban) have been demonstrated to be safe as monotherapy for DVT. These agents
have similar efficacy to warfarin in preventing PE, while having fewer reported bleeding episodes than warfarin. As such, the most recent
American Society of Hematology Guidelines from 2020 recommended DOACs over warfarin for the management of DVT or PE in most
patients.
Parenteral pre-treatment for 5-10 days followed by the DOAC Dabigatran
The direct thrombin inhibitor dabigatran is another option for oral anticoagulation that has similar advantages to rivaroxaban and apixaban. It
has not been studied as monotherapy, however, so it is recommended that patients be initiated on LMWH or other parenteral anticoagulant for
5-10 days prior to starting them on dabigatran.
Parenteral treatment bridge with initiation of warfarin
Warfarin takes several days to reach therapeutic efficacy, so simply starting it alone carries an unacceptable risk of PE. Thus, patients must
be started on either LMWH or unfractionated heparin while waiting for the patient’s INR to come into the therapeutic range (2-3). LMWH is the
preferred anticoagulant to pair with warfarin in most settings and may be administered in the outpatient setting.
Requirements for Treating DVT on Outpatient Basis
In order to treat DVT on an outpatient basis:
The patient must be:
Hemodynamically stable
With good kidney function
At low risk for bleeding
Able to afford medications
Adherent to medications
The home environment must be:
Stable and supportive
Capable of providing the patient with daily access to INR monitoring (if using warfarin as the anticoagulant)
For many years, the standard of care for DVT management was admission to the hospital and administration of unfractionated heparin overlapping
with the initiation of warfarin. Now, most patients with DVT may be managed in the outpatient setting, though there are a few important exceptions.
Inpatient management remains the best option for patients who are hemodynamically unstable, who are at serious risk of acute bleeding with the
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initiation of anticoagulation (e.g. those with prior admission for gastrointestinal bleeding), or who have obstacles to outpatient management.
Examples of this include the inability to afford DOACs and LMWH, those who do not have adequate support at home, or who have a history of issues
with adherence to medications and treatment plans.
While it may not appear to be the most cost-effective decision to have to be hospitalized, in this case, it is the right decision in light of the
inability to get the patient appropriate treatment in a timely fashion that could be fatal if left untreated or undertreated.
DVT Therapy: Advantages of Low-Molecular Weight Heparin (LMWH) over Unfractionated Heparin
LMWH has several advantages over unfractionated heparin:
Longer biologic half-life so it can be administered subcutaneously once or twice daily
Laboratory monitoring is not required
Dosing is fixed
Evidence from meta-analyses suggest that LMWH is associated with fewer major bleeding complications than unfractionated heparin
LMWH may be used in the outpatient setting; whereas unfractionated heparin requires hospitalization as it is administered intravenously with the
dosage based on body weight and titrated based on the activated partial thromboplastin time. Even if hospitalized, enoxaparin (one of the LMWH) is
often used because it is safer and easier to administer than a continuous heparin drip, one advantage of unfractionated heparin is that it can be
immediately shut off and reversed in the case of bleeding due to its very short half-life. In a patient with significant bleeding risk (e.g. recent
admission for gastrointestinal bleeding), it is advisable to choose unfractionated heparin over low molecular weight heparin, which has a much longer
half-life once injected. Unfractionated heparin also does not require renal dose adjustments.
DVT Treatment After Initial Stabilization
After initial stabilization with a therapeutic anticoagulant to prevent thrombus progression, a decision must be made on the primary treatment to
promote resolution of the thrombus and for how long. DOACs and warfarin remain the mainstays of this treatment phase.
Direct Oral Anticoagulants
DOACs are direct-acting agents that are selective for one specific coagulation factor, either thrombin (e.g., dabigatran) or factor Xa (e.g., rivaroxaban,
apixaban, and edoxaban, all with an “X” in their names)
Direct thrombin inhibitors
Dabigatran is a direct thrombin inhibitor that may be taken orally. Dabigatran also has been demonstrated in meta-analyses to lead to fewer bleeding
complications compared to warfarin. The reversal agent (idarucizumab) was approved by the FDA, which may be useful in the case of serious
bleeding.
Factor Xa inhibitors
Fondaparinux is a parental form of this class of drugs and could be used instead of LMWH in the initiation stage. Rivaroxaban and apixaban are
oral factor Xa inhibitors which may be used immediately as monotherapy for VTE. Although these drugs have been found to be as effective as, and
generally safer (i.e. fewer bleeding complications) than warfarin and LMWH, the negatives of this class of medications include high cost. Andexanet
alfa was recently approved as a reversal agent, though its availability may be limited depending on hospital setting.
One big advantage of DOACs is they don’t require frequent laboratory monitoring and dose adjustments. An important contraindication is that neither
direct thrombin inhibitors nor factor Xa inhibitors may be used in pregnant patients (unlike heparin, they cross the blood-placenta barrier) or in
patients with significant renal disease.
Warfarin
Prothrombopenic drugs like warfarin are not suitable for initial therapy in thromboembolism because their onset of action is too slow. Their only role is
in maintaining anticoagulant protection for prolonged periods. Before the development of the direct oral anticoagulants (DOACs), warfarin was the
mainstay of the management of DVT and still an acceptable option for many patients. Warfarin is a better option for patients who can’t afford the cost
of the DOACs, have difficulty taking medication more than once a day, or have a CrCl < 30 mL/min. Its disadvantages include its highly variable dosing range, its requirement of frequent laboratory monitoring, and its high rate of interactions with other medications. Warfarin requires monitoring. An INR is checked and the warfarin dose is titrated every three to seven days to achieve a goal INR of 2.0–3.0. Recommended Thromboprophylaxis Duration The duration of anticoagulation depends on whether the patient has a first episode of DVT and has ongoing risk factors for venous thromboembolic disease. Recommended duration of anticoagulation for a first proximal DVT (American Society of Hematology 2020 Guidelines). First proximal DVT or PE Recommended duration of Primary Treatment Transient risk factor (i.e. surgery) Provoked _______________ Chronic risk factor Recommended Secondary Prevention No 3-6 months ______________ Yes © 2023 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2023-12-26 22:34 EST 4/7 Unprovoked 3-6 months Yes The decision regarding the length of primary treatment and if a patient should continue anticoagulation indefinitely for secondary prevention must take into account various patient factors. The ASH recommends a minimum of three to six months for primary treatment of the DVT or PE. Secondary Prevention In general if there are risk factors that are chronic and unmodifiable (meaning the patient remains at risk of developing future clots) or the DVT/PE was unprovoked (occurred without an obvious reason), the overall risk of subsequent thrombus formation is higher and the patient is at greater risk of recurrence. In patients like this, continuing anticoagulation indefinitely is recommended as a form of secondary prevention. However, in patients who have an increased bleeding risk or the benefits of treatment may not outweigh the risks, it’s reasonable to not continue indefinite anticoagulation on a case by case basis. Treatment of Thrombotic Disease with Inherited Thrombophilia Some patients with inherited coagulation disorders are anticoagulated indefinitely after an episode of thrombotic disease. Criteria for Recommended Screening for Inherited Thrombophilia Although there are no absolute indications for screening for inherited thrombophilias, expert opinion on which patients are likely to benefit from such investigations includes patients with one of the following: Initial thrombosis occurring prior to age 40 without an immediately identified risk factor (e.g., idiopathic or unprovoked venous thrombosis). A family history of venous thromboembolism in a first-degree relative prior to the age of 50. Recurrent venous thrombosis. Thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins. If testing is being performed, it should not be done at time of VTE or while on anticoagulant therapy. There is currently no evidence to support any change in outcome when using such a strategy. Clinical Reasoning Differential of Unilateral Lower Extremity Edema Most Likely Diagnoses Lymphedema Lymphedema is generally painless, but patients may experience a chronic dull, heavy sensation in the leg. In the early stages of lymphedema, the edema is soft and pits easily with pressure. In the chronic stages, the limb has a woody texture and the tissues become indurated and fibrotic. Lymphedema initially involves the foot and gradually progresses up the leg so that the entire limb becomes edematous. Cellulitis is an acute inflammatory condition of the skin characterized by localized pain, erythema, swelling, and heat. Small breaks of skin are associated with streptococcal infection, whereas staphylococcal cellulitis is commonly associated with larger wounds, ulcers, or abscesses. Cellulitis Patients with diabetes are more susceptible to infections like cellulitis. Diabetic neuropathy causes an unawareness of abnormal pressure distribution. Ill-fitting shoes, cuts, or punctures can then lead to the development of ulcers. Vascular disease with diminished blood supply contributes to the development of the lesion, and infection is common. © 2023 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2023-12-26 22:34 EST 5/7 Classic symptoms of DVT include swelling, pain, and discoloration in the affected extremity. Physical examination may reveal the palpable cord of a thrombosed vein, unilateral edema, warmth, and superficial venous dilation. Classic signs of DVT include Homan's sign (pain on passive dorsiflexion of the foot), edema, tenderness, and warmth. While difficult to ignore, they are of low predictive value and can occur in other conditions such as musculoskeletal injury, cellulitis, and venous insufficiency. Chronic venous insufficiency may result from DVT and/or valvular incompetence. Following DVT, the valve leaflets become thickened and contracted so that they are incapable of preventing retrograde flow of blood; the vein becomes rigid and thickwalled. Although most veins recanalize after an episode of thrombosis, some may remain occluded. Secondary incompetence develops in distal valves because high pressures distend the vein and separate the leaflets. DVT Primary deep venous thrombosis can also occur without previous thrombosis. Patients with venous thrombosis often complain of a dull ache in the leg that worsens with prolonged standing and resolves with leg elevation. Examination reveals increased leg circumference, edema, and superficial varicose veins. The presence of a thrombus in a vein may be accompanied by an inflammatory response in the vessel which may be minimal or may be characterized by granulocyte infiltration, loss of endothelium, and edema. This inflammatory process may also result in a low-grade fever. Smoking and obesity are the most robust risk factors in the development of DVT. Diabetes, sedentary lifestyle, hypertension, hyperlipidemia, increasing age, prolonged immobility, surgery, trauma, malignancy, pregnancy, estrogenic medications (e.g., oral contraceptive pills, hormone therapy, tamoxifen (Nolvadex)), congestive heart failure, hyperhomocysteinemia, diseases that alter blood viscosity (e.g., polycythemia, sickle cell disease, multiple myeloma), and inherited thrombophilias are other potential risk factors in the development of DVT. Venous insufficiency The edema of venous insufficiency can be differentiated from chronic lymphedema as venous insufficiency edema is softer, and there is often erythema, dermatitis, and hyperpigmentation along the distal aspect of the leg. Skin ulceration may occur near the medial and lateral malleoli. Obesity is commonly associated with venous insufficiency. Peripheral artery disease (PAD) is the presence of systemic atherosclerosis in arteries distal to the arch of the aorta. As a result of the atherosclerotic process, patients with PAD develop narrowing of these arteries. Patients with PAD have a history of claudication, which manifests as cramp-like muscle pain occurring with exercise and subsiding rapidly with rest. In addition, later in the course of the disease, patients may present with night pain, nonhealing ulcers, and skin color changes. An ankle-brachial index (ABI) can be done to determine the presence of PVD. An ABI of < 0.9 is consistent with the disease. Peripheral artery disease Classic risk factors for PAD are smoking, diabetes mellitus, hypertension, and hyperlipidemia. Obesity (body mass index (BMI) > 30) increases risk for PAD as well.
Recent trials have added chronic renal insufficiency, elevated C-reactive protein levels, and hyperhomocysteinemia to the list
of risk factors.
The greatest modifiable risk factor for the development and progression of PAD is cigarette smoking. Cigarette smoking
increases the odds for PAD by 1.4 for every ten cigarettes smoked per day.
Arterial insufficiency is four times more prevalent in patients with diabetes than in those without diabetes. Nearly half of
patients who’ve had diabetes for 20 years or more have PAD, usually below the knees.
Wells Criteria for the Diagnosis of DVT
Active cancer (treatment ongoing or within previous six months or palliative)
1
Paralysis, paresis, or recent plaster immobilization of the legs
1
Recently bedridden for more than three days or major surgery within four weeks
1
Localized tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity) 1
Pitting edema (greater in the symptomatic leg)
1
Collateral superficial veins (non-varicose)
1
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Previously documented DVT
1
Alternative diagnosis as likely or more likely than that of deep vein thrombosis
-2
Low probability 0 or less, moderate probability 1–2, high probability 3 or more.
References
Arnold MJ. Venous Thromboembolism: Management Guidelines from the American Society of Hematology. Am Fam Physician. 2021;104(4):429-31.
Bauer KA. The thrombophilias: well-defined risk factors with uncertain therapeutic implications. Ann Intern Med. 2001;135:367-73.
Borgermans L, Goderis G, Van Den Broeke C, et al. Interdisciplinary diabetes care teams operating on the interface between primary and specialty care
are associated with improved outcomes of care: findings from the Leuven Diabetes Project. BMC Health Serv Res. 2009;9:179. Published 2009 Oct 7.
Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest
group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care.
2008;31(8):1679-85.
Connors JM. Thrombophilia Testing and Venous Thrombosis. N Engl J Med. 2017;377(12):1177-87.
Costantino G, Ceriani E, Rusconi AM, et al. Bleeding risk during treatment of acute thrombotic events with subcutaneous LMWH compared to intravenous
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