Robert Roberts Case: Deep Venous Thrombosis - PowerPoint Presentation Example

Background and Diagnosis
Mr. Roberts said the pain has been continuous for three days and he has quit taking his Ezetimbie because he thought it could be causing his pain. Mr. Roberts denies any chest pain, shortness of breath, fever, or headaches, indicating he is not currently at risk for these concerns.

DVT Cause
It is important to understand the cause of Mr. Roberts’s DVT to prevent future clots and to increase positive outcomes of his treatment. One of the biggest causes of DVT is surgery. Oftentimes, surgeons can damage venous walls or intercellular matrix, releasing clotting factors and causing DVTs (sloc.org). Mr. Roberts has not had any recent surgery indicating that this is probably not the cause of his DVT. DVT can also be caused by obesity and a sedentary lifestyle (sloc.org). Mr. Roberts’s BMI indicates that this is probably the cause of his DVT. In order to prevent future DVTs, Mr. Roberts should be counseled about increasing daily physical activity, making modifications to his diet, and the use of his hypercholesterolemia medication.

Another potential cause of Mr. Roberts’s DVT is his hypercholesterolemia. Increased lipids in the blood can form clots, which can lodge in the deep veins of the extremities and cause a DVT in some cases (sloc.org). Mr. Roberts’s DVT is probably exacerbated by the discontinuation of his hypercholesterolemia medication, as this behavior would increase his lipids and potentially add to previous clots or form new ones. In addition to his treatment regimen, Mr. Roberts should be counseled on the dangers of quitting his hypercholesterolemia medication without consulting medical personnel.

Treatment Regimen
There are two parts to Mr. Roberts’s treatment regimen: initial treatment and maintained treatment. The purpose of the initial treatment should be to control Mr. Robert’s partial thromboplastin time (PTT) and his INR while attempting to dissolve the clot in his leg. To achieve this, heparin is given initially in a bolus dose at 80 units/kg. After this initial bolus dose, Mr. Roberts will be on a maintenance dose of heparin at 16 units/kg. For Mr. Roberts, this means a 7000 unit bolus dose and a maintenance dose of 1640 units/hour which will continue for ten days. These doses were developed based on formulas posted on the accompanying PowerPoint presentation and were based on calculated dosage weight (surgery.ucsf.edu). During these ten days, Mr. Roberts’s PTT needs to be monitored every 6 hours until 2 consecutive in-range tests are performed. Adjustments to the dosage can be made based on the provided chart. Once in range, PTTs need to be done every 24 hours. After ten days, Mr. Roberts should be evaluated and hopefully can discontinue his heparin regimen.

The maintained treatment portion of Mr. Roberts’s treatment regimen is warfarin. When beginning warfarin, an initial INR needs to be taken in order to calculate an accurate dose. Based on Mr. Roberts's age, BMI, and use of hypercholesterolemia medications, 3mg was decided as an appropriate starting dose. Mr. Roberts’s INR should be measured daily and I have recommended an at-home testing device. Mr. Roberts's dose will need to be adjusted to make sure his INR falls in the target range of 2-3. Mr. Roberts will continue the warfarin daily until he can successfully maintain an INR of 2-3 without it. This should take between three and six months, but could potentially take longer (aafp.org).

Prognosis
Mr. Roberts’s prognosis is positive. The heparin and warfarin should dissolve the clot, and his INR should stabilize at normal over time. To prevent future DVTs, Mr. Roberts should be counseled on the use of elastic compression stockings, as well as on increasing his daily physical activity and making modifications to his diet to decrease his BMI. Mr. Roberts should also be counseled on the dangers of discontinuing his hypercholesterolemia medication. Mr. Roberts should be told to be aware of the warning signs of a pulmonary embolism or a stroke, such as fever, headache, wheezing, or shortness of breath. If Mr. Roberts has trouble with adhering to his regimen or with his at-home INR monitor, he could be referred to a local warfarin clinic for help.