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Increase warfarin dose
0%
0/0
CT angiogram of the chest
Ventilation/perfusion lung scan
Inferior vena cava filter
IV heparin
Select Answer to see Preferred Response
This patient is suffering from a deep vein thrombosis (DVT). The fact that the patient is already on a therapeutic dose of anticoagulant makes inferior vena cava (IVC) filter placement necessary. Anticoagulation is the primary prophylaxis and treatment for DVT. The patient is taking warfarin and has reached a therapeutic level of anticoagulation (INR 2.0 - 3.0). The appropriate action is to have an IVC filter placed as she has failed anticoagulation. An IVC filter would also be indicated if the patient had a contraindication to anticoagulation. Notably, anticoagulation does not dissolve the existing DVT. Thrombolytic therapy (i.e. tPA) may be used in cases of hemodynamically significant pulmonary embolism (PE). Wicky reviews the use of anticoagulants vs. thrombolytic therapy in DVT and complications thereof, and notes that anticoagulant therapy prevents the propagation of the existing acute DVT. As a complication of DVT, a significant number of patients will develop the postthrombotic syndrome (PTS), even after receiving anticoagulation therapy. Cosmi et al. reviews the use of oral anticoagulant therapy in venous thromboembolism and reports that heparin and oral anticoagulants (OACs) have been the traditional VTE treatment but are complicated to institute and administer. Low molecular weight heparins (LMWHs) have been introduced more recently and allow the home treatment of deep vein thrombosis (DVT) in selected cases. Illustration A shows a DVT on a doppler study. Incorrect answers Answer 1: The warfarin dose should not be increased as she is already in a therapeutic range of anticoagulation. Answer 2: A CT angiogram of the chest is used to diagnose PE, which is not suspected in this patient, nor would finding it incidentally alter management. Answer 3: A ventilation/perfusion scan, also known as a V/Q scan, is used to diagnose PE, which is not suspected in this patient, nor would finding it incidentally alter management. Answer 5: The patient is already therapeutically anticoagulated. IV heparin is not used in patients who have failed anticoagulation.
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