Ox-578 Tests Calculate Wells score (see table 13.5) before ordering D-dimer.

D-dimer is
sensitive but not specific for DVT (also ↑ in infection, pregnancy, malignancy, and post-op).
Wells score
≤1 point = DVT unlikely: Perform D-dimer. If negative, DVT excluded. If positive, proceed to USS
(if USS negative, DVT excluded; if positive, treat as DVT).
≥2 points = DVT likely: Do D-dimer and USS. If both negative, DVT excluded. If USS positive,
treat as DVT. If D-dimer positive and USS negative, repeat USS in 1 week.
Do thrombophilia tests (p374) before commencing anticoagulant therapy if there are no
predisposing factors, in recurrent DVT, or if DVT in unusual site. Look for underlying malignancy:
Urine dip; FBC, LFT, Ca2+; CXR ± CT abdomen/pelvis (and mammography) if >40yrs.
Prevention •Stop the oral contraceptive pill 4wks pre-op. •Mobilize early. •LMWH eg
enoxaparin 20mg/24h SC, ↑to 40mg for high-risk patients (p375) (caution if eGFR less
than 30mL/min/1.73m2). •Graduated compression stockings (‘thromboembolic deterrent
(TED) stockings’; CI: ischaemia) and intermittent pneumatic compression devices
↓risk of DVT by ~70% in surgical patients• Fondaparinux (a factor Xa inhibitor) ↓risk
of DVT over LMWH in eg major orthopaedic surgery without ↑ risk of bleeding.

Treatment LMWH (eg enoxaparin 1.5mg/kg/24h SC) or fondaparinux. LMWH is superior

to unfractionated heparin (used in renal failure or if ↑risk of bleeding; dose guided
by APTT, p350).
Cancer patients should receive LMWH for 6 months (then review).
In others, start warfarin simultaneously with LMWH (warfarin is prothrombotic for the
first 48h). Stop heparin when INR is 2–3; treat for 3 months in most.

Direct oral anticoagulants (DOACS p190), eg dabigatan, apixaban, rivoraxaban, are newer
alternatives licensed for the treatment of DVT with benefits relating to simpler dosing and
monitoring and ↓ bleeding risk.
Inferior vena caval filters may be used in active bleeding, or when anticoagulants fail, to
minimize risk of PE. Post-phlebitic change (pain, swelling, and skin changes) can be seen in 10–
30%— graduated compression stockings may help.

Gp-1465
Treatment See p818. If haemodynamically unstable, thrombolyse for massive
PE (alteplase 10mg IV over 1min, then 90mg IVI over 2h; max 1 . 5mg/kg if <65kg).
Haemodynamically stable: start LMWH or unfractionated heparin if underlying renal
impairment and treat for 5 days. Then, start DOAC (direct oral anticoagulant) or warfarin
(p350). For warfarin, stop heparin when INR is 2–3, due to intial prothrombotic
eff ect of warfarin (target INR of 2–3). Consider placement of a vena caval filter if
contra-indication to anticoagulation.
DVT risk
107.Obese Pt undergoing some surgery with BMI 32 and previous h/o of DVT...Asking which
will increase risk of DVT if he under goes surgery.? (no carcinoma is in options)
a- Spider naevi on chest
b- Nicotine stains on fingers
c- Bilateral varicose veins 
d- BMI
Ans: C

44.Pt comes with haematuria and this was the ct,asked what will increase the chance of DVT after
his operation
a.Nicotine stain of fingers 
b. Atrial fibrillation 
c.. Bilateral varicose veins
d. BMI 
e. Spider naevi on chest
Ans: C

DVT with surgery

Ortho-trauma-Sx notes>> 10
1. patient with uncomplicated varicose vein was admitted for elective surgery ,he has treated
with clopidogrel for coronary stent last 4 months ago so what is the management for him?
a) Reassess the indication of surgery again
b) Continue clopi 72hrs before surgery
c) continue clopi and defer the surgery for 1month
d) stop clopi 1 week before the surgery 
e) do surgery immediately
 Ans: A

2. Michael is a 60 years old man with history of TI a year ago and controlled hypertension and
DM. Three months ago, he had an episode of DVT and has been warfarnized since then. He has
been recently diagnosed with cholecystitis after stabilization with fluid and antibiotics he will have
his elective surgery in 5 days, what will be your plan of management of warfarin pre operatively?
A- Change to heparin until two days before surgery then check INR
B- Cease warfarin today until the day of surgery
C- Measure the INR, if it’s less than 5 continue warfarin
D- Cease warfarin and change to LMWH from the 4th day until the 12 hours before surgery 
E- Cease warfarin and change to heparin now
Ans: D Warfarin ceases at least 5days b4 surgery

pic of cancer colon, patient on warfarin after cardiac stent for 6 months Came to u in ER,, what
initial
a. Change warfarin to clopigrel and after 10 d proceed to operation
b. Stop warfarin and give vit k and proceed now
c. Stop warfarin and give ffp and proceed now
d. Stop warfarin for 10 d and proceed to operation
Ans: acute complication + in pic or acute abdomen >> C
Answer change to A

46.pt has drug eluting stent 2 months before. Per rectal bleeding not so much ....and not
continuous ...... Advised to do colonoscopy....what to do?
1- cease both and colonoscopy
2-cease clopidogrel and do colonoscopy
3-cease aspirin and do colonoscopy
4-continue both and do colonoscopy
Ans: 4 but cant take biopsy

Investigations
3. Pt with Lt leg symptom of DVT he is diabetic and has numbness in both legs and no absent
pulse long hx what next investigation
Doppler of Lt leg
Arterial duplex of both legs
Ans: Duplex USG
Gp-1465 Investigations
• Duplex ultrasound: accurate for above-knee thrombosis; improving for distal calf Should be repeated in 1 week if
initial test is normal
• Contrast venography: reserved if ultrasound doubtful
Note:
• MRI appears to be very accurate for DVT, but is not yet available generally.
• The plasma D-dimer can be helpful. Where the clinical probability of venous thrombosis is low, a normal D-dimer
effectively excludes the diagnosis. Where clinical probability is high, appropriate imaging with Doppler ultrasound
or lung scan should be performed. A raised D-dimer is non-specific and does not help with diagnosis.

49. patient with AF... pain in legs.. right leg is pallor absent pulses... ix
(acutely >> embolism>> 6P)
A ct angiogram (usually used in chronic)
B uss veins
C uss leg
D d dimer
Ans: A
Management
4. Pt with complains typical of DVT.V/Q scan showed reduced lung segment perfusion
A)LMWH
B)Warfarin
C)CTPA
D)Antibiotics
Ans: A
Pt is stable or not?
Score? >4= immediate CTPA, if not LMWH, Score<4= LMWH

5. patient with hx of dvt... has dyspnea chest pain. Vq scan shows no perfusion in a lung
segment . Mx
A enoxapirin SC
B Thrombolysis
C warfarin
Ans: A

19.Middle aged man come with calf muscle pain, by examination you find an infalmmed cord
with firm nodules under the skin what to do:
A. Heparin
B. Analgesic and mobilization
C. Corticisterois and rest
Ans: A superficial thrombophlebitis

16. Post-operative patient with the past medical history of DVT. Other than normal mechanical
compression for prevention of DVT. What other treatment would prevent post op DVT?
A. No treatment is necessary
B. Enoxaparin while bed rest
C. Enoxaparin for 6 weeks
D. Enoxaparin for 10 days
Ans: D
Abdominal surgery- 7-10 days

75. Man with DVT on warfarin and enoxaparin (1mg/kg bd). Still has symptoms after a few days.
INR 1.8
a) increase heparin and maintain warfarin dose
b) increase warfarin and maintain heparin dose
c) maintain both at current dose
d) change to some other drug (can't remember)
Ans: A
Care
108. A 22 years old woman came to your surgery for contraception advice. Her mother and
sister had DVT episodes. Which one of the following is best step in the care of this patient?
A- Ask for family history of breast or ovarian cancer
B- Do thrombophilia screening
C- Prescribe combine oral contraceptive pill
D- Prescribe low dose combine oral contraceptive pill 
E- Do lower limb Doppler ultrasound
Ans: B inherited thrombophilia>> activated pr C deficiency, factor v laden Gp-1464, Ox-374