Last updated on 03 Aug 2023 at 8:35 AM (Blood03)

Deep vein thrombosis
While on your GP placement you see a 45 year old NZ European woman who has just returned from holiday in London. She has noticed that her left leg has become swollen and painful. This has never happened to her before but her sister has had a 'clot in the leg' in the past. During the consultation, the GP remembers that she started the patient's 15 year old daughter on the combined oral contraceptive pill a few weeks ago, without her mother's knowledge.

 

Applied Science for Medicine
Anatomy of venous system
Mechanisms that promote venous blood flow in the lower limbs
Virchow's triad
Mechanisms controlling haemostasis: platelets and coagulation factors. Laboratory assessment of these including effects of anticoagulants and antiplatelet agents
Factor deficiencies, genetic diseases and conditions that create a procoagulant environment
Pharmacology of warfarin, heparin and low-molecular weight heparin, dabigatran, rivaroxaban

Clinical and Communication Skills
History from a patient with a swollen limb; assess risk factors for a deep vein thrombosis
Perform and record an examination of a swollen limb; use dermatological terminology to describe skin changes and recognise neurovascular compromise
Indications for venous duplex ultrasound of the lower limb and thrombophilia screen
Interpret D-dimer result
Differential diagnosis of swollen limb
Calculate Wells score for deep vein thrombosis
Management of deep vein thrombosis, pulmonary embolus and haemorrhage while anticoagulated
Complications of deep vein thrombosis
Perioperative management of anticoagulation
Role of thrombosis service and pharmacist for patients on anticoagulants
Pharmacological and non-pharmacological preventions of deep vein thrombosis and pulmonary embolism
Warfarin counselling
Strategies to prevent post-thrombotic complications
Management of patient on warfarin with international normalised ratio (INR) greater than therapeutic range

Personal and Professional Skills
Ethics regarding treatment in minors
Ethics involved with care of family/whānau members

Hauora Māori
Ability to cater for differential health literacy needs of Māori patients and whānau particularly in regard to warfarin treatment
Awareness of differing risk profiles for Māori (and other disadvantaged populations) compared with non-Māori in New Zealand when presenting with deep vein thrombosis (such as underlying cancer)
Consideration of access to cultural/spiritual support for patient and whānau including advice on rongoa and interactions with warfarin

Population Health
Epidemiology of deep vein thrombosis: risk factors, associated conditions, prevention and awareness

 

Conditions to be considered relating to this scenario

Common

deep vein thrombosis, cellulitis, ruptured Baker's cyst, peripheral vascular disease, Achilles tendonitis, venous stasis dermatitis

Less common but 'important not to miss'

polycythaemia vera, heart failure, antiphospholipid syndrome, antithrombin defiency, factor V Leiden, protein C/S deficiency, dysfibrinogenaemia, necrotizing fasciitis, pulmonary embolism

Uncommon

lymphoedema, thrombophlebitis, stress fracture