Thrombosis Consult

Identification: Mrs. Evelyn Hayes, [age 68], residing in London, was referred to the thrombosis clinic for management of a deep vein thrombosis (DVT) in her left leg. She has a past medical history of hypertension and hypercholesterolemia. Reason for Referral: Mrs. Hayes was referred due to a confirmed DVT and the need for assessment and management of anticoagulation therapy. Thrombosis History: Mrs. Hayes presented with sudden onset of left leg swelling and pain on 20 October 2024. A Doppler ultrasound confirmed the presence of a DVT in the left popliteal vein. She was initially treated with enoxaparin. Anticoagulation History: Currently on enoxaparin 1mg/kg twice daily, started on 20 October 2024. No bleeding complications reported. INR control is not applicable as she is on enoxaparin. Other Past Medical History: * Hypertension * Hypercholesterolemia Medications: * Lisinopril 10mg daily * Atorvastatin 20mg daily * Enoxaparin 1mg/kg twice daily Allergies: * No known drug allergies. History of Presenting Illness: Mrs. Hayes reported the sudden onset of left leg swelling and pain. She denies any recent surgery, trauma, or prolonged immobility. Review of systems is unremarkable. She denies any constitutional symptoms. Family History: * Mother: History of stroke. * Father: Died of a heart attack. Social History: Mrs. Hayes is a non-smoker and drinks alcohol occasionally. She is retired and enjoys walking. She has not travelled recently. Physical Examination: * Vitals: BP 140/80 mmHg, HR 78 bpm, RR 16, SpO2 98% on room air. * General: Alert and oriented. * Cardiovascular: Regular rate and rhythm. * Respiratory: Clear to auscultation bilaterally. * Extremities: Mild edema in the left lower extremity, calf circumference 2cm larger than the right, no tenderness or erythema. Laboratory Results: * CBC: Within normal limits. * D-dimer: Elevated. * Coagulation profile: Within normal limits. * Renal/Liver function: Within normal limits. Imaging: * Doppler ultrasound of the left leg confirmed DVT in the popliteal vein. Impression and Plan: Mrs. Hayes presents with a confirmed DVT in the left leg. The plan is to continue enoxaparin and transition to warfarin. **Educate patient on warfarin and INR monitoring.** **Schedule follow-up appointment in one week for INR check and clinical review.** **Discuss thrombophilia screening.**