How to solve a nursing Aquifer virtual case: Complete the History, Physical Exam, and Assessment (Solved)

Assignment: Complete the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 07: 53-year-old male with leg swelling.
You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.
DOMAIN: HISTORY
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.

Table of Contents

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.
5a) what are possible causes of swelling? (In a short paragraph, 5-7 lines)
5b) what are the risk factors of peripheral arterial disease, PAD? (In a short paragraph, 5-7 lines)

Family Medicine 07: 53-year-old male with leg swelling
Authors: Robert Mallin, MD
INTRODUCTION
HISTORY

The waiting room at the family clinic
You are working at a family medicine clinic with Dr. Hill. She tells you, \”The next patient, Mr. Smith, is a 53-year-old male with a chief concern of swelling and pain in his left lower extremity.\”
Before you go to see Mr. Smith, a quick review of the chart reveals that he has type 2 diabetes, obesity, hypertension, and hyperlipidemia. You note that he has not been to the office in the past six months, and it appears that he should be out of all of his medications.
When you enter the examination room, Mr. Smith, a middle-aged male, greets you from where he is sitting. You introduce yourself and ask him what brings him to the office today.
He replies, \”It\’s my left leg. The past four days it has been red, swollen, and painful—and it seems to be getting worse.\”
You ask him to tell you more about this problem.
He says, \”It began several days ago, and the swelling seems to be getting worse. It hurts all the time; it doesn\’t even get better when I rest it. It seems to get a little worse when I move around. It hurts to walk as soon as I try to stand on it.\”
REASON FOR VISIT
HISTORY

You meet Mr. Smith and interview him about his leg problem.
Now that you have a general sense of Mr. Smith\’s issue, you ask more focused questions.
\”Did you do anything to injure your foot?\”
He replies, \”I do not remember any injury, but there has been this sore on the bottom of my foot for several months. There\’s nothing draining out of the sore and it doesn\’t hurt, although my foot doesn\’t have much feeling in it.\”
\”Before this happened, were you sitting down for a long time without getting up and using your legs, such as taking a long airplane trip; or have you been on bed rest?\”
\”I wish I could go somewhere on an airplane and get a good vacation, but I can\’t afford anything like that. I haven\’t been on bed rest. I\’ve been pretty busy lately.\”
\”When was the last time you were in the office?\”
\”It has been a long time now because my daughter and new baby recently moved in with me and I have been trying to take care of the baby as well as keep my job as a bus driver,\” he explains.
\”Have you been taking your medication?\”
He replies, \”I have been out of my medication for several weeks now.\”
After talking with Mr. Smith more, you discover:
Social History: Does not drink alcohol, but does smoke 1.5 packs of cigarettes daily, he is unmarried, and lives in public housing with his three children and one grandchild.
Review of Systems: No fever or chills, no chest pain, no shortness of breath, and no swelling of the right leg.
PHYSICAL EXAM 1
PHYSICAL EXAM

You measure the diameter of Mr. Smith\’s leg.
You examine Mr. Smith and find:
Vital Signs: T 36.5 °C (97.8 °F), BP 140/90, HR 85, RR 12, O2 98%
Cardiovascular and lung exam: Unremarkable
Lower extremity exam:
Mr. Smith\’s entire left leg is swollen, warm and erythematous. The measurement of the circumference of the largest left calf section is 3.5 cm larger than his right calf at the same location.
There is pitting edema. The leg is tender to the touch, especially along the distribution of the deep venous system.
Dorsalis pedis and posterior tibialis pulses are palpable on both feet. Digital capillary refill time is two seconds. Deep tendon reflexes are present (2+).
He has decreased sensation and is unable to determine the location of a monofilament test on either foot up to the ankle in a stocking distribution.
You note a 2 cm ulceration on the plantar surface of Mr. Smith\’s left foot.
At this point, you excuse yourself to discuss your findings with Dr. Hill, assuring Mr. Smith you will return in a few moments.
SUMMARY STATEMENT
CLINICAL REASONING
Question
Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.
More on summary statements.
A summary statement should:
1. Include accurate information and not include misleading information.
2. Facilitate understanding of the primary problem and appropriately narrow the differential diagnosis through the inclusion of pertinent key features. (The aim is to frame understanding of the primary problem rather than to report all information indiscriminately.)
3. Express key findings in qualified medical terminology (e.g., heart rate of 180 beats/minute is tachycardia); synthesize details into unifying medical concepts (e.g., retractions + hypoxia + wheezing = respiratory distress).
4. Use qualitative terms that are often binary in nature (e.g., acute versus chronic; constant versus intermittent).
Ultimately, a good summary statement should provide an understanding of the patient presentation while being concise, complete, and accurate.
Your response is recorded in your student case report.
Letter Count: 0/1000
SUBMIT
Answer Comment
Mr. Smith is a 53-year-old male with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use who presents with a four-day history of left lower extremity edema. He reports no fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity. On exam he is afebrile. The entire left leg is swollen and erythematous, and his left calf is 3.5 cm larger in circumference than his right. There is an ulcer on the plantar surface of his left foot.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
1. Epidemiology and risk factors: 53-year-old man with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use
2. Key clinical findings about the present illness using qualifying adjectives and descriptive language:
• Four-day history
• Unilateral
• No fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity
• Afebrile
• Left Leg circumference 3.5 cm greater than right
• Edema and erythema involving entire leg
• Associated plantar ulcer
DIFFERENTIAL DIAGNOSIS
CLINICAL REASONING
Question
Dr. Hill asks you to consider a differential diagnosis.
Choose five of the following that are at the top of your differential given what you know of Mr. Smith so far.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Cellulitis
• B. Deep venous thrombosis
• C. Lymphedema
• D. Muscle strain
• E. Peripheral artery disease
• F. Popliteal cyst
• G. Venous insufficiency
SUBMIT
Answer Comment
The correct answers are A, B, C, E, G.
Most Likely Diagnoses
Mr. Smith\’s concern of swelling that is unilateral is an important finding to support the diagnosis of cellulitis, lymphedema, or deep vein thrombosis (DVT). In contrast, for venous insufficiency one would expect bilateral leg swelling. Peripheral artery disease (PAD) is not particularly associated with edema.
Cellulitis and DVT are acute processes. Lymphedema, PAD, and venous insufficiency are less likely, given the acute nature of Mr. Smith\’s symptoms.
Since PAD, venous insufficiency, and lymphedema are not infectious processes, the lack of fever in Mr. Smith\’s case keeps these diagnoses on the differential.
• In Mr. Smith\’s case, the acute unilateral swelling, erythema, and warmth in a diabetic patient, make cellulitis (A) likely. The presence of a fever would support the diagnosis of an infectious process like cellulitis. But the fact that Mr. Smith does not have a fever doesn\’t rule out a diagnosis of cellulitis as it is certainly possible to have localized cellulitis without fever.
• In Mr. Smith\’s case, you feel that the acute nature of his symptoms—the unilateral swelling, and the presence of risk factors such as obesity, smoking, and diabetes—make DVT (B) a very likely diagnosis. Mr. Smith does not have a fever, but the inflammatory process due to a thrombus in his vein could explain his unilateral lower extremity edema.
• Lymphedema (C) can be present unilaterally, however this is usually a more chronically developing problem, making this diagnosis less likely.
• While venous insufficiency (G) could contribute to the development of a DVT, the acute and unilateral nature of Mr. Smith\’s symptoms make you think a diagnosis of venous insufficiency alone is less likely.
• In Mr. Smith\’s case, a diagnosis of PAD (E) seems unlikely given the lack of claudication and normal pulses on examination. Although PAD may not be the primary cause of Mr. Smith\’s leg swelling and pain, it could potentially be contributing to it by increasing his risk for a foot ulcer. Mr. Smith\’s history of smoking and diabetes increases the likelihood that he has PAD.
Less Likely Diagnoses
Muscle strain (D)—Although this can be a cause of swelling and pain, in a patient with intact mental status, a history of trauma should be present to consider this.
Popliteal cyst (F)—This should be palpable behind the knee and rarely would cause the extensive swelling and pain seen in Mr. Smith.
TEACHING POINT
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 • 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.
• 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.
DVT • 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 thick-walled. 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.
• 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 • 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.
• 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.
References
Ely JW, Osheroff JA, Chambliss ML, Ebell MH. Approach to leg edema of unclear etiology. J Am Board Fam Med. 2006;19(2):148-60.
Firnhaber JM, Powell CS. Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. Am Fam Physician. 2019;99(6):362-9.
Freedman JE, et al. Arterial and Venous Thrombosis. In: Jameson J, et al. Harrison\’s Principles of Internal Medicine, 20e. McGraw Hill; 2018. Accessed September 8, 2021.
McLendon K, Goyal A, Bansal P, Attia M. Deep Venous Thrombosis Risk Factors. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 22, 2021.
Pierson Bruner L. Applying a Clinical Prediction Rule to Distinguish Lower Extremity Cellulitis from Its Mimics. Am Fam Physician. 2021;104(3):309-10.
Stevens DL. Infections of the Skin, Muscles, and Soft Tissues: Cellulitis. In: Jameson J, et al. Harrison\’s Principles of Internal Medicine, 20e. McGraw Hill; 2018. Accessed September 8, 2021.
Wilbur J, Shian B. Diagnosis of deep venous thrombosis and pulmonary embolism. Am Fam Physician. 2012;86(10):913-9.
DIAGNOSTIC TESTS 1
TESTING
Dr. Hill praises you, \”Very nice clinical reasoning. It looks as though you have correctly narrowed your differential down to two primary diagnoses: cellulitis and deep venous thrombosis (DVT). It is important to make sure when crafting a differential for unilateral lower extremity swelling that DVT is always on that list as it’s a condition that can lead to death if missed. Let\’s consider what type of information would be most helpful to obtain next.\”
Question
Which of the following diagnostic tests is the best initial test with high predictive value for determining whether your patient has cellulitis or DVT?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Complete blood count
• B. Erythrocyte Sedimentation Rate
• C. D-dimer
• D. MRI of the affected extremity
• E. Venous Doppler of the lower extremity
SUBMIT
Answer Comment
The correct answer is E.
Venous Doppler of the lower extremity (E) should tell you with good sensitivity and specificity if a DVT is present. A Complete Blood Count (A) and an erythrocyte sedimentation rate (B) are elevated in various inflammatory states and can be elevated in patients with a DVT or cellulitis thus an elevated value would not rule DVT in nor would a normal value be specific enough to rule out DVT. D-dimer (C ) is a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is a relatively sensitive, but poorly specific test for the presence of DVT. While a negative result (low D-dimer concentration in the blood) practically rules out thrombosis, a positive result can indicate thrombosis but does not rule out other potential causes, such as infection. Its main use, therefore, is to exclude thromboembolic disease when the pretest probability is low. An MRI (D) could identify the presence of thrombus, however is expensive compared to venous doppler.
TEACHING POINT
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
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.
References
Ebell MH. Diagnosis: making the best use of medical data. Am Fam Physician. 2009;79(6):478-80.
Thompson IM, Ankerst DP, Chi C, et al. Operating characteristics of prostate-specific antigen in men with an initial PSA level of 3.0 ng/ml or lower. JAMA. 2005;294(1):66‐70.
DIAGNOSTIC CRITERIA
TESTING

You and Dr. Hill discuss DVT as a possible diagnosis for Mr. Smith.
Dr. Hill asks:
\”What test do you think we should order?\”
You tell Dr. Hill, \”I guess we should have a Doppler ultrasound done because it has the best predictive value for a DVT.\”
\”Suppose I told you that this test was relatively expensive and often overused,\” Dr. Hill proposes, \”Would that change your thinking?\”
You respond, \”Well you mentioned that the D-dimer test is highly sensitive. Perhaps we could rule out DVT by doing that one.\”
\”Very good thinking. That is precisely the appropriate role of that study. But, remember that the D-dimer test is best used to rule out a DVT if the pretest probability of having a DVT is relatively low.\”
\”Is there some way to estimate Mr. Smith\’s pretest probability of having DVT?\”
\”I have read that no singular clinical finding is helpful in that,\” you tell her.
\”That is true,\” Dr. Hill concurs. \”But if we use several clinical findings, we may be able to do a better job of predicting pretest probability. I am speaking here of the Wells criteria.\”
TEACHING POINT
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
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.
Question
Given what you know of Mr. Smith so far, which of the following is likely to represent his pretest probability of DVT?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Cannot determine
• B. High probability
• C. Low probability
• D. Moderate probability
SUBMIT
Answer Comment
The correct answer is B.
Review of Mr. Smith\’s history and physical exam reveals that he has:
• Localized tenderness along the distribution of the deep venous system (1)
• Entire leg swollen (1)
• Calf swelling by more than 3 centimeters compared with the asymptomatic leg (measured 10 centimeters below the tibial tuberosity) (1)
• Pitting edema (greater in the symptomatic leg) (1)
Note, one aspect of the Wells criteria for the diagnosis of DVT is an alternative diagnosis as likely or more likely than that of deep vein thrombosis (-2). While cellulitis is a possible explanation for Mr. Smith\’s condition, DVT is much more likely, especially given his obesity and history of smoking.
Mr. Smith\’s score is 4; a high pretest probability (B).
Incorrect Answers: You can determine his pretest probability using the Wells Criteria. A low probability score is 0 (C), a moderate probability score is 1–2 (D).
References
Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226-56.
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8.
DIAGNOSTIC TESTS 2
TESTING
You conclude, \”Given Mr. Smith\’s high pretest probability of DVT, I don\’t think I would trust a negative D-dimer result even with its high sensitivity. I think we have to get Mr. Smith a Doppler ultrasound instead.\”
Dr. Hill agrees. \”Ultrasonography is recommended as the initial test in a patient with high pretest probability.” And adds, \”are there other diagnostic studies that you would order now?\”
Question
Which of the following would you order at this point?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Arterial blood gas
• B. Chest x-ray
• C. Complete blood count
• D. C-reactive protein
• E. Electrolytes, glucose, creatinine, and blood urea nitrogen (BUN)
• F. Hemoglobin A1C
• G. Sedimentation rate
• H. Thyroid studies
SUBMIT
Answer Comment
The correct answers are C, E, F.
A CBC (C ) with leukocytosis might make you consider an infectious process. Given you are in clinic and he has not been seen in almost 6 months electrolytes, glucose, BUN & creatinine (E) as well as a Hemoglobin A1c (F) would be important to evaluate diabetic control and renal function.

Arterial blood gas (A) or chest x-ray (B) in a patient without symptoms of respiratory difficulty is unlikely to be useful.
Sedimentation rate (G) and c-reactive protein (D) might be elevated, but would be in both cellulitis and DVT, so it is not particularly useful in determining a diagnosis at this point.
Thyroid studies (H) are unlikely to provide any useful information about the absence of signs and symptoms of thyroid disease.
References
Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226-56.
PHYSICAL EXAM 2
PHYSICAL EXAM

Dr. Hill walks you through a diabetic foot exam.
You and Dr. Hill return to Mr. Smith\’s room together. After greeting him, Dr. Hill explains, \”Mr. Smith, we have a good idea of what may be causing the issues with your leg. We would like to gather some more information by taking a blood sample and sending you over to radiology for a Doppler ultrasound so that we can determine the best course of treatment for you.\”
After Mr. Smith assents to the plan, Dr. Hill washes her hands and asks to take a look at his leg. She agrees with your assessment.
She walks you through a diabetic foot examination:
On Mr. Smith\’s exam, Dr. Hill finds 3 out of 10 sites imperceptible using the 10-gram monofilament test, indicating some loss of protective sensation.
She finds Mr. Smith\’s dorsalis pedis and posterior tibialis pulses intact bilaterally.
She notes a 2 cm ulcer on the plantar surface of his foot, with some surrounding erythema, and callous formation. The ulcer is deep, including full skin thickness, down to muscles and ligaments, but no exposed tendons, or bony involvement, and there appears to be no abscess formation.
She finds that the skin on Mr. Smith\’s feet is dry and his toenails are dystrophic and incurvated, demonstrating inappropriate self-care.
At the end of the diabetic foot exam, Dr. Hill turns to you and asks, \”What do you think we should do about his foot ulcer?\”
You admit, \”I\’m not sure about that. Would antibiotics help?\”
\”They would if his wound is infected, but first we should evaluate the grade of the ulcer,\” Dr. Hill explains.
TEACHING POINT
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.
Question
Which of the following describes the grade of Mr. Smith\’s ulcer?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Grade 1
• B. Grade 2
• C. Grade 3
• D. Grade 4
• E. Grade 5
SUBMIT
Answer Comment
The correct answer is B.
• Mr. Smith\’s ulcer is grade 2 (B).
It is a deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. However, Mr. Smith\’s wound does not demonstrate any signs of infection.
• Mr. Smith\’s ulcer is more serious than grade 1 because it is not superficial (A)
• Mr. Smith\’s ulcer is not as serious as grade 3 (C) because it does not involve abscess formation or osteomyelitis. It is not grade 4 (D) or 5 (E) because it does not involve gangrene.
Dr. Hill emphasizes at this point that based on clinical examination, it does not appear that Mr. Smith has cellulitis and more likely his diagnosis will be a DVT.
TEACHING POINT
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.
References
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.
Family Practice Notebook. Foot Wound https://fpnotebook.com/Surgery/Derm/FtWnd.htm Published March 22, 2010. Accessed October 19, 2021.
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996;35(6):528-31.
REVIEWING LAB RESULTS
CLINICAL REASONING
You and Dr. Hill determine that Mr. Smith\’s foot ulcer does not require antibiotics at this time, but does require debridement, which you will address after he\’s had his tests done. Mr. Smith has his blood drawn and a Doppler ultrasound performed.
A few hours later, you see that the results of the labs have returned:
Complete Blood Count:
Lab Value Conventional SI
WBC 7.5 x103/μL 7.5 x109/L
Hgb 13.7 g/dL 137 g/L
Hemoglobin A1C 10.2 % .102
Chemistry:
Lab Value Conventional SI
Na 137 mEq/L 137 mmol/L
K 4.0 mEq/L 4.0 mmol/L
Cl 98 mEq/L 98 mmol/L
C02 25 mEq/L 25 mmol/L
BUN 18 mg/dL 6.3 mmol/L
Creatinine 1.0 mg/dL 88 mmol/L
Glucose 232 mg/dL 12.7 mmol/L
See the associated reference ranges in conventional and SI units.
Question
Which of the following best describes the findings above?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. An infectious process
• B. Uncontrolled diabetes
• C. Uncontrolled diabetes and anemia
• D. Uncontrolled diabetes and an infectious process
• E. Uncontrolled diabetes and renal dysfunction
SUBMIT
Answer Comment
The correct answer is B.
Elevated glucose and HGBA1c are evidence of uncontrolled diabetes (B).
WBC is normal (A, D), which does not support an infectious process. Between the lack of leukocytosis, the lack of fever, and the clinical findings of a grade 2 ulcer, cellulitis is now a very unlikely diagnosis for Mr. Smith.
While there is evidence for uncontrolled diabetes, renal function (BUN & creatinine) appears normal (E) and he is not anemic because he has a normal hemoglobin (C).
FORMULATING A PLAN
CARE DISCUSSION

You and Dr. Hill discuss proper treatment for Mr. Smith.
Dr. Hill informs you, \”I just received a call from the radiologist. It looks as if our suspicions were correct. Doppler ultrasound shows that Mr. Smith has a DVT in the femoral vein. So now the question is: What do we do about it?\”
You respond, \”Well he needs anticoagulation to prevent a pulmonary embolus (PE), right?\”
\”Right. His short-term risk of a PE is high, so we need to anticoagulate him right away.\”
TEACHING POINT
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.
TEACHING POINT
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
Question
Which of the following can be an appropriate treatment option for the initial management of an acute DVT?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Dabigatran
• B. Low molecular weight heparin (LMWH) overlapping with the initiation of warfarin
• C. Rivaroxaban
• D. Unfractionated heparin overlapping with the initiation of warfarin
• E. Warfarin
SUBMIT
Answer Comment
The correct answers are B, C, D.
Rivaroxaban (C) can be initiated on its own for the treatment of acute DVT. Unfractionated heparin or LMWH overlapping with the initiation of warfarin is also appropriate (B, D). Both Warfarin (E) and Dabigatran (A) cannot be initiated as monotherapy. Warfarin requires overlap (also known as bridging) with unfractionated heparin or LMWH. Dabigatran requires lead-in or pretreatment of a parenteral anticoagulant (such as heparin or LMWH) for 5 to 10 days prior to initiating.
TEACHING POINT
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.
References
Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020;4(19):4693-738.
DISCUSSION OF TREATMENT
CARE DISCUSSION
Dr. Hill calls Mr. Smith\’s pharmacy and finds that his insurance will only cover dabigatran and does not cover any other DOAC. Unfortunately, insurance does not cover the necessary pre-treament parenteral agent enoxaparin (injectable low molecular weight heparin) without prior approval, which may take a few days to achieve. (It is late in the day when you are seeing him.) Dr. Hill asks you if you think he would be better managed in the hospital or as an outpatient.
After thinking about it for a minute you respond, \”I don\’t think it is acceptable to send him home if we can\’t ensure that he will be able to get enoxaparin or one of the DOACs that can be used for monotherapy tonight. His day-to-day risk of a pulmonary embolus is too high. Also, I am worried about his ability to adhere to new complicated instructions, given that he has a busy home and work life and has not been able to prioritize his own care. He needs to have a plan for managing his medications and he has this foot ulcer that needs care. I think it would be best to stabilize him in the hospital and work on having a more supportive home environment.\”
Dr. Hill replies, \”Excellent. I agree that Mr. Smith will be best treated in the hospital. Let\’s look into how we will do that.\”
TEACHING POINT
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 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.
TEACHING POINT
Parenteral Agents
There are three parenteral therapies used to either bridge with warfarin or pretreat prior to initiation of dabigatran: unfractionated heparin, low-molecular weight heparin (LMWH), and fondaparinux.
Question
Which of the following is true about LMWH?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Dosing is fixed with LMWH.
• B. Laboratory monitoring is not required for LMWH.
• C. LMWH does not require renal dose adjustments
• D. LMWH has a longer biologic half-life so it can be administered subcutaneously once or twice daily.
• E. LMWH may be used in the outpatient setting.
SUBMIT
Answer Comment
The correct answers are A, B, D, E.
LMWH has fixed dosing (A), does not require laboratory monitoring (B), has a longer biologic half-life (D), and may be used in the outpatient setting. LMWH requires renal dosing at CrCL < 30 mL /min whereas heparin doses are adjusted based on PTT levels (C).
TEACHING POINT
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.
References
Costantino G, Ceriani E, Rusconi AM, et al. Bleeding risk during treatment of acute thrombotic events with subcutaneous LMWH compared to intravenous unfractionated heparin; a systematic review. PLoS One. 2012;7(9):e44553.
Robertson L, Jones LE. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for initial treatment of venous thromboembolism. Cochrane Database Syst Rev. 2017 Feb 9;2:CD001100.
IMPLEMENTATION OF TREATMENT PLAN
THERAPEUTICS
You and Dr. Hill decide to have Mr. Smith anticoagulated on LMWH because it doesn\’t require laboratory testing and dosage titration and Mr. Smith may be more comfortable if he\’s not hooked up to an IV.
Dr. Hill adds, \”We only want to use low molecular weight heparin for a short term. After five days we will start dabigatran since he will need a longer course of anticoagulant therapy to reduce his risk of PE. In his case, his risk factors are not readily reversible, which will factor into our thinking about the duration of his treatment. If, for example, he had developed his DVT as a complication of surgery (a common and transient risk factor), we would have less cause for concern about his risk for recurrence of his DVT.\”
TEACHING POINT
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.
Question
What is the minimum amount of time Mr. Smith should remain anticoagulated for the primary treatment of his DVT?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. One month
• B. Two months
• C. Three months
• D. Six months
• E. Twelve months
SUBMIT
Answer Comment
The correct answer is C.
In Mr. Smith\’s case, he has a first episode of proximal idiopathic (unprovoked) thromboembolic disease with a low risk of bleeding. Guidelines suggest that he should be anticoagulated for at least three months (C). Data clearly demonstrate that recurrence rates are high for treatment durations shorter than three months, thus A and B are incorrect. The option exists to extend this treatment for a total of six months (D) based on clinician and patient choice. There are currently no recommendations for 12 months (E) of anticoagulation for VTE.
TEACHING POINT
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 Recommended Secondary Prevention
Provoked Transient risk factor (i.e. surgery)
_______________
Chronic risk factor 3-6 months No
______________
Yes
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.
References
Arnold MJ. Venous Thromboembolism: Management Guidelines from the American Society of Hematology. Am Fam Physician. 2021;104(4):429-31.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-52.
Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020;4(19):4693-738.
MULTIDISCIPLINARY CARE
MANAGEMENT

You and Dr. Hill discuss an endocrinology consult.
Dr. Hill says, \”Since we are planning on treating Mr. Smith in the hospital, one of the advantages of inpatient treatment is that we can get the wound team nurse to evaluate his ulcer and make some recommendations. While we have Mr. Smith in the hospital, are there other specialists or team members that we can involve to improve his health?\”
You suggest, \”What about an endocrinologist to help with diabetes management?\”
\”Now there\’s an interesting thought. What do you think is complicating Mr. Smith\’s glucose control?\”
You contemplate this, \”In thinking about his history, it seems that he has been nonadherent with his medication regimen, diet, exercise program, and his follow-up appointments for some time. He describes a stressful social situation at home with family and financial problems, as well as work-related stress.\”
\”How do you think an endocrinology consult will help with that?\” Dr. Hill wants to know.
\”I see your point,\” you admit. \”His problems in managing his chronic illness seem to be more social than medical.\”
\”That\’s right.\” Dr. Hill adds, \”It\’s possible that an endocrinology consult might be useful down the road, especially if he is brittle or otherwise difficult to control on routine medication, but we really have not had the opportunity to see if standard care will be successful because of his social factors.\”
\”So, I guess it might be better if we get some recommendations from a diabetes educator, a social worker and maybe even the Pharm D,\” you suggest.
\”Excellent! Ideally, we could all meet in a room and map out a plan for his care, but this isn\’t practical in reality. Instead, our role, as the family clinician, is to assume responsibility for coordinating and directing his care and ensuring that everyone on the team is working toward the same goal.\” Dr. Hill explains.
TEACHING POINT
Family Physicians Coordinate Comprehensive Multidisciplinary Care
Family medicine physicians play an essential role in optimizing patient care by coordinating comprehensive multidisciplinary care.
References
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.
FURTHER THERAPEUTIC CONSIDERATIONS
TEACHING
Dr. Hill explains to you the importance of testing for inherited thrombophilia, \”Patients with DVT secondary to an inherited thrombophilia are treated differently than others.\”
TEACHING POINT
Treatment of Thrombotic Disease with Inherited Thrombophilia
Some patients with inherited coagulation disorders are anticoagulated indefinitely after an episode of thrombotic disease.
Question
Which of the following criteria are potential reasons to screen for inherited thrombophilia?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. A family history of venous thromboembolism.
• B. All patients with deep venous thrombosis (DVT) should be screened for inherited thrombophilia.
• C. Initial thrombosis occurring prior to age 40 without an immediately identified risk factor (e.g., idiopathic or unprovoked venous thrombosis).
• D. Recurrent venous thrombosis.
• E. Thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins.
SUBMIT
Answer Comment
The correct answers are A, C, D, E.
Initial unprovoked thrombosis occurring before age 40, family history of venous thromboembolism, recurrent venous thrombosis, and thrombosis occurring in unusual vascular beds are all potential reasons to screen for inherited thrombophilias. There is no indication to screen all patients who present with a DVT.
TEACHING POINT
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.
There are no indications to screen all patients with deep venous thrombosis (DVT) for thrombophilia (B).
According to these indications, Mr. Smith\’s situation does not warrant screening for thrombophilia.
References
Bauer KA. The thrombophilias: well-defined risk factors with uncertain therapeutic implications. Ann Intern Med. 2001;135:367-73.
Connors JM. Thrombophilia Testing and Venous Thrombosis. N Engl J Med. 2017;377(12):1177-87.
Nicolaides AN, Fareed J, Kakkar AK, et al. Prevention and treatment of venous thromboembolism–International Consensus Statement. Int Angiol. 2013;32(2):111-260.
DISCUSSING THE PLAN WITH THE PATIENT
CARE DISCUSSION

You explain to Mr. Smith the risks of a blood clot.
You and Dr. Hill return to Mr. Smith\’s exam room to discuss your findings and recommendations with him.
Dr. Hill begins, \”Mr. Smith, the reason your leg is so swollen and painful is that you have a blood clot in one of your veins. The good news is that we can treat this condition quite easily and quickly. We would like to admit you to the hospital to treat the blood clot that you have and start you on some medication which will keep you from getting another clot.\”
\”Hospitalization? I don\’t have time to go into the hospital. I have a job and a family to take care of.\”
\”I understand that,\” Dr. Hill assures him. \”I hear you saying that it is very difficult to take care of yourself and your family, especially in this day and time, and I agree. But, if we don\’t treat the blood clot in your leg, there\’s a real risk that it will travel to your lungs and could kill you. You will only need to be in the hospital for a few days, and we would like to use this time to get your other health issues, like high blood pressure and diabetes under control. We also need to take care of that ulcer on your foot.\”
\”It sounds like I don\’t have much of a choice. I guess I\’ll have to go to the hospital. Why do I have a blood clot, anyway?\” Mr. Smith wants to know.
You tell him, \”Well, as we\’ve discussed before, your smoking puts you at significant risk for a blood clot. Although you may not be aware, the fact that your body weight is higher than recommended also puts you at some risk of a blood clot. After we\’ve addressed this immediate problem with your blood clot, we\’d like to see you here at the clinic to revisit your smoking and your weight to see if we can work together to reduce your risk of another blood clot, as well as improve your health overall.\”
Mr. Smith seems satisfied, and preparations are made for the hospital admission.
Question
Which of the following are known health risks of obesity?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Breast cancer
• B. Coronary heart disease
• C. Endometrial cancer
• D. Gallbladder disease
• E. Lung cancer
• F. Obstructive lung disease
• G. Obstructive sleep apnea
• H. Osteoarthritis
• I. Stroke
SUBMIT
Answer Comment
The correct answers are A, B, C, D, G, H, I.
Obesity is associated with many poor health outcomes, such as cardiovascular disease (including hypertension, dyslipidemia, stroke (I), and coronary heart disease (B)); osteoarthritis (H) due to physical stress on joint from carrying excess weight; obstructive sleep apnea (G); gallbladder disease (D); and several cancers (including breast (A), endometrial (C), pancreatic, renal, and colon). Lung cancer (E) has not been associated with obesity. While obesity is a cause of restrictive lung disease, it is not associated with obstructive lung diseases (F).
FOLLOW-UP 1
TEACHING

Mr. Smith is feeling better after hospitalization.
Several days have gone by and you and Dr. Hill are now rounding on your patients in the hospital. When you get to Mr. Smith, you tell Dr. Hill:
\”This is Mr. Smith\’s third day in the hospital. He says he is feeling better, the pain and swelling in his leg is improving. His temperature is 36.2 °C (97.2 °F), his pulse is 80 beats per minute, his respiratory rate is 16 breaths per minute, his blood pressure is 128/78 mmHg. On exam, his foot ulcer has some fresh granulation tissue on the wound edges. Labs include his fasting glucose this morning was 128 mg/dL (7.0 mmol/L). His CBC was normal and his platelets are stable from admission.\”
Dr. Hill responds, \”Good. I just got word from his pharmacy that the enoxaparin has now been approved by his insurance, so if he can inject himself for two more days, he can go home. We will need to arrange a close follow-up with visiting nurses and at our office, so he can continue his treatment for his diabetic foot ulcer.\”
You comment, \”This all seems so much easier than it would have been if he were taking warfarin. How long would it take to get his INR to the therapeutic range if he were using warfarin?\”
Dr. Hill tells you, \”It varies a lot from person to person, but it commonly takes at least five days for a patient\’s INR to get above 2.0. When starting it, you have to balance speed with the risk of overshooting his INR goal and ending up increasing his risk of bleeding by making him supratherapeutic. It is good to consider warfarin dosing since it is still commonly used. It is a very effective medication, but it can be dangerous as well.\”
TEACHING POINT
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.
Question
Dr. Hill poses a hypothetical question to you: Suppose Mr. Smith is on warfarin instead of dabigatran, and his INR comes back as 11.2 and he has no signs of active bleeding. Which of the following is the most appropriate approach to take next?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Continue current dose of warfarin, recheck INR at 5 days
• B. Discontinue warfarin, give 5 mg Vitamin K IV and repeat until INR less than 4.0
• C. Discontinue warfarin, give Vitamin K 2.5mg orally, recheck INR in 24 hours
• D. Discontinue warfarin, administer 4-factor prothrombin complex concentrate (PCC), and repeat INR in 24 hours
• E. Omit one dose of warfarin and resume warfarin the next day
SUBMIT
Answer Comment
The correct answer is C.
Recommended action when goal INR is overshot.
If the goal INR is substantially overshot, it increases the risk of bleeding complications significantly.
Warfarin should be held and INR needs to be monitored closely. An oral dose of Vitamin K can be given to reduce INR and prevent bleeding complications ( C).
It is inappropriate to continue warfarin at the current dose because of risk of bleeding (A). Giving 5 mg Vitamin K IV (B) or giving 4 factor PCC (D) in a non-bleeding patient could lead to overcorrection of INR and increase thrombotic risks. Holding one dose of warfarin may be sufficient in bringing the INR down, but resuming warfarin without an INR check to ensure they are in the therapeutic range may cause worsening INR and increased risk of bleeding (E)
DEEP DIVE
References
Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S-e184S.
Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv.2018;2(22):3257-91.
FOLLOW-UP 2
MANAGEMENT

Dr. Hill asks about home arrangements for Mr. Smith.
\”What do you think we should do next?\” Dr. Hill wants to know.
After contemplating this for a moment, you conclude, \”Since his insurance has now approved the prior authorization for 2 days of enoxaparin he can finish the pretreatment phase at home. He has been on enoxaparin for three days now. My understanding is that he needs to be on enoxaparin for 5 days and then he can begin the dabigatran. He will need to be able to give himself the enoxaparin at home for 2 days and then be able to start the oral dabigatran about 12 hours after his last dose of enoxaparin. His floor nurse has been showing him how to give the injections, so I think he will be able to do it. He said he doesn\’t like it very much, but he would do it if he has to.\”
You continue, \”He\’s back on his regular medications which have improved his blood pressure and glucose. The foot ulcer has been debrided and is getting better. There doesn\’t seem to be much more for us to do in the hospital, so I think he might be ready to go home later today.\”
\”I agree,\” Dr. Hill replies. \”What type of arrangements will he need at home?\”
\”Home health should be able to manage his wound. I would think with that and close follow-up in the office, he should do well,\” you predict. “We also need to make sure he understands the timing of the enoxaparin and transition over to the dabigatran, and that he knows where to pick up both his medications.
You also remind Dr. Hill that Mr. Smith\’s obesity and smoking still pose tremendous risks to his health and that in future visits to the clinic, he should be counseled regarding weight loss and smoking cessation as well as managed for hypertension, hyperlipidemia, and diabetes.
References
Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):454S-545S.

SOLUTION TO THE AQUIFER CASES

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

The first area that the healthcare provider failed to address was family history related to the presenting illness. “Is there a family member that has ever had leg swelling problems or DVT?”

The second question omitted was about associated symptoms like warm sensation on the affected limb. “Does the affected limb feel warmer than the other?”

1b) Explain your rationale for asking these two additional questions.

Taking a family history during an assessment is important as it helps to identify risk factors for certain health problems. Leg swelling is a sign that can indicate medical conditions like DVT that are associated with the presence of genetic risk factors in the family (Gasparis et al., 2020). The second question about warm sensation on the affected limb involves a description of associated symptoms with leg swelling. Asking this question is important because it can help the provider generate a list of differentials and also guide in reaching the actual diagnosis.

1c) Describe what the two (2) additional questions might reveal about the patient’s health.

Family history can identify individuals who are at a higher risk than the usual chance of having certain health conditions. While leg swelling is not a common health condition, it can indicate that the patient has DVT, problems with arterial perfusion, or cellulitis (Gasparis et al., 2020). Inherited conditions like DVT and thrombophilia can result in the observed symptoms. Understanding the patient’s history can help in planning for treatment and follow-up. The second question might reveal whether the patient has DVT which is usually associated with warm sensation on the affected limb.

DOMAIN: PHYSICAL EXAM

For each system examined in this case;

2a) Explain the reason the provider examined each system.

Mr. Smith’s physical examination began with assessing his Vitals that revealed normal results. It was important to take the patient’s vitals to guide the assessment of other systems while identifying other underlying health conditions that the patient may not be aware of. A detailed examination was done on his left leg to assess the state of the swelling and other associated symptoms. It was important to conduct a focused examination to identify the actual cause of the swelling and obtain measurements that could guide objective assessment.

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.

Abnormal findings were observed on Mr. Smith’s left leg. The provider observed that the leg was swollen, warm, and erythematous. The measurement of the leg circumference on the calf region indicated that it was 3.5 cm larger than the right leg at the same location. Further examination revealed pitting edema, and tenderness on touch especially on the distribution of the deep venous system. The patient also had diminished sensation and was unable to determine the location of a monofilament test on either foot up to the ankle region. The plantar surface of the left foot had ulceration that the patient thought did not affect his functioning. These findings demonstrate that Mr. Smith has a serious health problem on his left leg that requires immediate diagnosis and treatment.

2c) Describe the normal findings for each system.

The patient’s vitals revealed the following: Signs: Temperature 36.5 °C (97.8 °F), Blood Pressure 140/90, Heart Rate 85, Respiratory Rate 12, and Oxygen saturation 98%. Examination of the cardiovascular and respiratory systems revealed unremarkable results. Based on the patient’s health status, examination of the other systems was not necessary. A focused examination of the left leg was the most important aspect of his care. While most of the results from the focused assessment were abnormal, normal findings included 2+ deep tendon reflexes, capillary refill of 2 seconds in both extremities, and palpable dorsalis pedis and posterior tibialis pulses on both feet. These findings indicated that the patient had no issues with blood circulation to the lower extremities.

2d) Identify the various diagnostic instruments you would need to use to examine this patient.

The instruments for examination will include a thermometer, BP machine, pulse oximeter, stethoscope, tape measure, and a monofilament to test for loss of protective sensation.

DOMAIN: ASSESSMENT (Medical Diagnosis)

Discuss the pathophysiology of the:

3a) Diagnosis and,

The diagnosis for the patient is deep venous thrombosis (DVT) following the clinical presentation and Doppler ultrasound results. DVT is a subset of venous thromboembolism (VTE) that is a major preventable cause of morbidity and mortality worldwide (Stone et al., 2017). The pathophysiology of DVT is mainly associated with Virchow’s triad that describes three crucial factors leading to thrombus formation. These factors include hypercoagulability, stasis, and endothelial damage. Venous thrombosis tends to occur in areas with diminished blood flow like pockets in deep veins (Stone et al., 2017). While valves usually help in promoting blood flow, they can form pockets for stasis and hypoxemia. As blood flow slows down, oxygen tension declines which lead to increased hematocrit. The hypercoagulable microenvironment in the veins is altered leading to the expression of P-selectin and tissue factor that cause thrombus formation (Stone et al., 2017). Decreased blood flow and formation of clots further activate the coagulation cascade leading to the release of factor VII, VIII, and prothrombin that cause further clotting.

3b) Each Differential Diagnosis

The differential diagnosis for DVT that can be established based on the signs and symptoms of the patient is cellulitis. Cellulitis is a common bacterial infection characterized by erythema, warmth, edema, and tenderness on palpation (Raff & Kroshinsky, 2016). The infection usually follows a breach in the skin such as ulceration, fissure, or puncture wound. Microorganisms gain entry into the dermis through the punctured surface. The majority of the cases are caused by streptococcus pyogens while others can be caused by staphylococcus aureus (Raff & Kroshinsky, 2016). Upon infection with these microbes, cytokines and neutrophils are recruited to the affected area leading to inflammation. The response to infection leads to the production of antimicrobial peptides and keratinocyte proliferation that causes the observed signs and symptoms.

DOMAIN: LABORATORY & DIAGNOSTIC TESTS

Discuss the following:

4a) What labs should be ordered in the case?

The patient presents with signs of infection and based on his history of diabetes, obesity, and hypertension, the following labs should be ordered. A complete blood count, electrolytes, glucose, creatinine, and blood urea nitrogen, and hemoglobin A1C levels.

4b) Discuss what lab results would be abnormal.

Abnormal findings for Mr. Smith include elevated blood glucose levels (232mg/dl). The patient explains that he has not been checked for the past six months and has not been on medication despite his diagnosis. It is anticipated that his blood glucose levels will be high.

4c) Discuss what the abnormal lab values indicate.

Elevated blood glucose levels indicate uncontrolled diabetes. Uncontrolled diabetes is characterized by constantly high blood glucose levels above 180 mg/dl and can be a serious cause of health problems like kidney failure, DKA, and diabetic foot. With the patient’s left leg swelling, uncontrolled sugars may impair healing and cause more damage to his foot that is already ulcerated.

4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.

A Doppler ultrasound is the most common test used to diagnose DVT. The test will be used to show blood flow in the veins and any blood clots that exist (Gasparis et al., 2020). The test can also be used to identify the area where the clots have formed to guide in formulating treatment.

5a) What are possible causes of swelling?

Leg swelling occurs because of an abnormal accumulation of fluid in the tissues of the lower extremities. The swelling is mainly caused by problems with the venous circulation system, the lymphatic system, or the kidneys (Gasparis et al., 2020). The swelling is mostly observed in overweight individuals, those that sit or stand for long hours or wear tight stockings. Factors related to the buildup of fluid may include DVT, chronic kidney disease, pulmonary hypertension, or peripheral artery disease.

5b) What are the risk factors of peripheral arterial disease, PAD?

Peripheral arterial disease (PAD) involves narrowing or blockage of the vessels carrying blood to the heart as a result of plaque buildup in the arteries. The risk factors for the disease include smoking, high blood pressure, atherosclerosis, high cholesterol levels, diabetes, and the elderly above 60 years (Centers for Disease Control and Prevention (CDC), 2021). The condition causes pain in the legs, especially with physical activity.

References

Centers for Disease Control and Prevention. (2021). Heart disease: Peripheral arterial disease (PAD). https://www.cdc.gov/heartdisease/PAD.htm

Gasparis, A. P., Kim, P. S., Dean, S. M., Khilnani, N. M., & Labropoulos, N. (2020). Diagnostic approach to lower limb edema. Phlebology, 35(9), 650–655. https://doi.org/10.1177/0268355520938283

Raff, A. B., & Kroshinsky, D. (2016). Cellulitis: A review. JAMA, 316(3), 325–337. https://doi.org/10.1001/jama.2016.8825

Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: Pathogenesis, diagnosis, and medical management. Cardiovascular Diagnosis and Therapy, 7(Suppl 3), S276–S284. https://doi.org/10.21037/cdt.2017.09.01

How to solve a nursing Aquifer virtual case: Complete the History, Physical Exam, and Assessment (Solved)

SOLUTION TO THE AQUIFER CASES

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