DVT

Harold was a 71-year-old male who resided in the nursing home because of a medical history of multiple sclerosis (MS). He could no longer take care of himself and had no family. He needed to be lifted to his motorized wheelchair via the Hoyer lift. Harold was very good at driving his motorized wheelchair around the long halls in the long-term care facility. He did need help with bathing, grooming, and changing his clothes but could feed himself in the dining room with set-up and some assistance.

Harold was a new patient for me and in order for me to get to know his medical history better I needed to sit down with his chart and go through the labs and tests that were done; every medication he was taking and why; his vital signs; his weight and if there were any changes; the nurse’s notes and if there were any problems; and recent orders from his previous provider. Once I felt I knew him medically it was time to meet him for the first time. I walked down the hallway to his room. He was in the first bed by the door. I lightly knocked on the door. I noticed the blue motorized wheelchair sitting off in the corner and the Hoyer lift at the end of the hallway. I looked at my watch and saw it was 1015 on a Tuesday morning. He was sitting up in his bed looking like he just finished a short nap.

“Good morning Harold. I am the nurse practitioner. How have you been today?” I asked.

“Ok I guess, “he replied.

“How have you been feeling?” I asked. I watched him fidget with his shirt.

“Ok I guess.” I asked him the usually questions about having pain, if his bowel and bladder were working, if his appetite was good, any problems…etc. He denied all and said he was ok.

After completing his history and physical and finding the usual abnormal neurological findings for MS patients I looked at his legs. I lifted the sheet and saw both legs were abnormally edematous. The right was larger than the left and the edema went up to the groin and down to each foot. I felt for pedal pulses and they were +2 bilaterally. The edema was 4+ pitting on his right leg and 3+ pitting on his left.

“Do your legs hurt you?” I asked.

“Sometimes,” he replied.

“When do they hurt you?” I asked. He thought about it for a while.

“When they move me sometimes they hurt,” said Harold.

“How long have they hurt you when they move you?” I asked. He thought about what I said.

“I don’t know.” I watched him and knew he had nothing more to say.

“Well I am done with my exam Harold. I am going to have some tests done on your legs today. They worry me because they are so swollen.”

“Okay.”

I walked down the hallway to the room where I charted. I quickly glanced at his medical history and medications again. I wanted the test to be done STAT which meant in the long-term care facility within the next two to three hours. I pulled out an order sheet and wrote, “VENOUS DOPPLER BILATERAL LEGS R/O DEEP VEIN THROMBOSUS (DVT) STAT.” If I did not write the word STAT on the order it would get done sometime later today. I needed to know the results sooner. At least at this time of morning I knew I would get the results by 1400, hopefully sooner. I also wrote the order for Harold to stay in bed until the results were back. The risk of moving a patient with a suspected DVT was the clot moving towards the lungs, brain, or heart. Pulmonary embolus can be a fatal consequence of the clot moving. I wanted to lower that chance and keep Harold in bed. He would need to eat his lunch in bed which would not make him happy. The nurse’s told me he loved to ride in his motorized wheelchair. I kept a progress note for me to document my findings and gave the chart back to the nurse so she could expedite the venous doppler. A company was contracted with the facility to do portable venous doppler’s which made ordering these type of tests much easier for the patient. The test would be done in Harold’s room.  

The ultrasound technician responded quickly to the facility because he was nearby at another facility. I looked at my watch and it was 1130. I needed to see other patients so I let him do his work. Harold already verbalized his dissatisfaction with having to stay in bed but cooperated with the test. The ultrasound technician was done within ten minutes. Harold was cooperative although grumpy. I needed to drive to another building to see a patient who had fallen. I asked the nurse to please call me as soon as she got the results of Harold’s doppler.

It was 1300 and my phone rang. I looked at the number on my digital reader and saw it was Harold’s facility. I suspected it was the doppler results and already had the gut feeling what the results were.

“Hi. This is the nurse practitioner,” I said into the phone.

“Hi. This is Ruth. We got Harold’s results back just now. I will read the interpretation,” she said.

“Ok.”

“It says he has bilateral thrombus from his popiteal to his groin,” said Ruth.

“Wow,” I replied.

“Yea. Something huh?” she said.

“How much does Harold weigh again?” I asked. I heard Ruth flipping through his chart. After a few seconds she had the answer.

“He weighed 157 pounds at the beginning of this month. He eats well so I am pretty sure it is accurate,” said Ruth. I did the calculation in my head.

“What are his allergies?”

“None.” I thought for a few seconds.

“Lovenox 70mg SQ BID. Give him Coumadin 10mg po NOW. Then Coumadin 5mg po qd. Get a PT/INR in two days and every two days until we get his INR above 2. Then we need to get him therapeutic with an INR between 2 and 3,” I said. I could hear writing in the background. After several seconds the writing stopped.

“Ok. I will get that going as soon as possible. We need to wait for the pharmacy to deliver it. Does he stay in bed until then?” asked Ruth.

“Yes. He needs to stay in bed until he receives his Lovenox. Then he can get in his motorized wheelchair,” I replied.

“Ok.”

Harold’s INR was drawn every two days for a week before it was between 2.3 and 2.7. At that time I discontinued the Lovenox and continued checking the INR every two days until I could get his dose adjusted correctly. After a week both of his legs were tremendously smaller. The anticoagulation was working and I hoped his large clots in both of his legs would dissolve and not cause any problems. Harold was getting around happily in his motorized wheelchair.

After two weeks and adjusting the Coumadin to 2.5mg qd Harold became therapeutic and stabilized. His legs looked normal. He would remain on Coumadin probably for the rest of his life to prevent more DVT’s. He was at risk for DVT’s due to the lack of ambulation which stimulated blood flow to his leg muscles. He normally was either in his bed or motorized wheelchair, neither allowed for good blood flow to his lower extremities. The order was changed for him to get the PT/INR drawn every Monday.

After four weeks Harold’s INR remained between 2.2 and 2.8. His legs continued to look normal without edema or pain. He continued to ride the long-term facilities hallways with his motorized wheelchair. He did not question the new medication he was taking although he verbalized he was glad the shots in his stomach were over with. I discussed with him on several occasions why he needed to be on Coumadin. He replied, “Ok.”