SOAP Assessment: Deep Vein Thrombosis

Initials of Patient: P.W.D

Patient Age: 60

Patient Ethnicity: African American

Initials of Provider: S.M.W

Clinical Setting: Hospital

Patient Status: Deep Vein Thrombosis (DVT)

Chief Complaint

An elderly man of 60 years reports to the clinic with various complaints, which include:

· Excessive pain on one of the legs that have been swelling especially at the calf

· Tenderness of the affected leg’s skin with some notable paleness

· Pain in the ankle and the knee

History of Present Illness

· The man reports that he has been having leg cramps since he underwent orthopedic surgery a month ago

· Says that the pain seems to be increasing every day especially in the ankles despite walking more often to exercise his muscles.

· He adds that he has since stopped playing golf because the pain is rather severe. Before undergoing the orthopedic surgery, he reported that he did not have the symptoms apart from the issue of a sprained ankle which he indicates was third-degree leading to corrective surgery.

Constitutional:

· Cardiovascular- Patient reports shortness of breath for the last few months

· Musculoskeletal- he confirms a recent ankle sprain

· Skin/Integument- the patient says the skin on the leg has been pale for the last few weeks

· Psychiatric: he says that he takes anti-depressants

The Past Medical History

· Has been overweight for the last year

· For the last 30 years, he has been occasionally consuming alcohol, but the frequency has increased.

· He has been suffering from depression for the last three years, thus, he has been taking antidepressants and in some cases goes for psychotherapy sessions.

· Reports sporting injuries in the last year, especially on the knee and the ankle

The Past Social History

· African American and lives in Columbia in a house that he built 20 years ago.

· He has a master’s degree in education and has been a lecturer in one of the local universities before his retirement five years ago.

· Currently occupied with small scale farming

· A widower and lives with one of his grandchildren. He has three sons who live in different regions, and he rarely sees them.

· Reported having a wonderful time hanging out with his peers in a local pub at least twice a week

· Refers to his drinking as occasional, which is 2 to 3 times a week.

· Has been playing golf in his free time and taking walks.

· Reports no sexual activity since his wife’s death

Psychiatric History

He has a history of depression which started after his wife’s death. He reports that he finds solace in occasional drinking, despite being on antidepressants. In some few instances, he went for psychotherapy, which he has since quit. Throughout his parenting, he says that he never thought that he would grow distant with his sons, who hardly visit him to check on his well-being. He loves his grandson who lives with him as he goes to a school nearby. He has visited therapeutic sessions, but he is unable to continue because the expenses are too high. He takes anti-depressants irregularly and finds more comfort in consuming alcohol with his friends who are from his neighborhood.

Hospitalizations

· Was hospitalized a month ago in order to undergo orthopedic surgery and he stayed in the district hospital for one week. The medications given were mostly painkillers (opioids) taken for five days. He went back to the hospital twice for dressing.

· Other medications include antidepressants that he has been taking for more than a year, but this has not been on a regular basis.

· Currently, he is taking Tylenol to relieve the recurrent ankle pain. The patient reports that he is not allergic to any food.

· Has no records for past immunizations and cannot remember the instances he has been immunized.

· His diet is mostly comprised of vegetables as he hopes to become a full vegetarian in an attempt to control his weight. He also takes daily evening walks because he is not able to engage in more demanding exercises.

Family History

· 60 years old

· A widower

· Three sons living in other regions

· Currently living with one of the grandsons who is 18 years

· Lives on the family land where he farms

· Loves playing and watching golf

· Rarely travels

· Affiliated to one of the Roman Catholic Churches in Columbia

· His peers are the main social support group

Objective Data

Vital signs

After close examination of the patient, the following vital signs were notable after the clinical objective diagnostic tests.

· Skin discoloration around the affected extremity

· Unilateral Oedema

· Calf Tenderness

· exterior venous dilution

· warmth around the affected extremity

Oxygen saturation

The patient’s peripheral capillary oxygen saturation level was at 90%

Ht: 5’9

Wt: 200 Lbs

BMI: 29.5

Constitutional:

General

A sixty-year-old African American in severe distress

Physical Examination

Blood Pressure: 185/190 of Hg,

Heart Rate: 100 beats per minute

Temperature: 37.8 ° C

Respiratory Rate: 31

Head: Notable depression

Ears: Ossicles not in appearance but hearing intact

Eyes: conjunctiva not clear, abnormal optical discs but visual acuity is intact

Nose: Mild external lesions, mucosa partly inflamed

Mouth: Well moist mucosa membrane, mild mucosa lesions

Throat: Tonsillar Hypertrophy and exudates

Neck: Notable lesions, tender, and enlarged thyroid

Coronary: S1 and S2 Normal,

Respiratory: Numerous rales, Wheezing, and notable Rhonchi Cardiac: Notable murmurs Breast: No notable abnormality on breast nipples. GI: Within limits GU: Testes and epididymides not in normal size, notable masses and Lesions in Scotrum

GYN (female): Reproductive (Male): normal Musculoskeletal: tenderness and misalignment, increased range of motion, abnormal strength in lymph extremities

Skin/Integument: Skin discoloration and rashes Psychiatric: Oriented X3, depression

Neuro: CN 2 – 12 Normal, Within Limits Endocrine: Heat and cold Intolerance Hematologic/Lymphatic: Enlarged lymph nodes Allergic/Immunologic: Drug Allergy

Laboratory Results

•Ca -8.8 (8.5 to 10.2 mg/dL)

•K -4.0 (3.5-5.3 mEq/L) • BUN -37 (7 – 20 mg/dl) • Cr -1.2 (0.8 to 1.4 mg/dl)

Na -140 (135 -145 mEq/L) •Hct -55 (40.7 – 50.3%) •Alb -4 (3.4 – 5.4 g/dL) •Hgb -17.5(14-17.5g/dl) •Cl -101 (96 – 106 mEq/L) •WBC 8.1(3.8 – 10.8 thous/mcl ) •Glu -95 (70-120 mg/dL) •Uric acid -7.47.4(3.0 -7.0mg/dL) •TBili -0.8(0.3 to 1.9 mg/dL)

• P04 -2.6(2.5 – 4.5mg/dl) • AST- 40(5-40U/L) • ALT -35(5-40U/L) •PT -25 (12-15 sec) •INR=3(0.8-1.2)

Main Diagnosis

WBC discrepancy: N 47, L 29, M 5, E20 •Gram stain of sputum test was incongruous owing to abundant squamous epithelial cells

•Urinalysis: Within limits

•Chest x-ray: Clear, no symptoms of infections

•ABGs: pH 7.35, PO257, PCO248

Assessment

Deep Vein Thrombosis

Subjective

There was no complaint sufficient to support the conclusion of DVT while the patient may have indicated some few signs that may have been linked to Deep Vein Thrombosis, and the subjective section did not provide a conclusion.

Objective

There were notable swings in the last year, especially in the last several months, in the measurements of International random ratio that has confirmed these swings. In the last two months, the International random ratio in the patient has seemed to stabilize at a constant 3.0. The constant level of INR at 3.0 may not be good enough for the patient given that there is a need to achieve an INR that is closer to 1.0 (Kesieme, Jebbin, Irekpita, & Dongo, 2011). In this regard, while the levels of INR seem to stabilize the patient is still at risk.

Assessment

Notably, the patient had only one reported instance of deep vein thrombosis; the best alternative in this instance is the warfarin therapy. Ideally, the purpose of warfarin therapy is to ensure that the treatment is discontinued after the first six months of treatment. The other alternative would be heparin in an instance when the deep vein thrombosis is recurrent.

Plan

The plan, in this case, is to successfully follow the warfarin therapy for six consecutive months and then discontinue it (Center for Disease Control and Prevention, 2016). The patient will also be educated to engage more in physical activities such as sports in order to enhance recovery. The patient will be educated on what better food should he eat; this includes foods rich in vitamin E such as fatty fish. The other important aspect is the change of diet in order to ensure that BMI returns to a healthy level, as the current level BMI indicates that the patient may be overweight.

Risk factors

The risk factors involved in the development of deep vein thromboses include the aftermath of major surgery such as a hip replacement. The other notable risk factor is cancer. Finally, the risk of deep vein thrombosis is also increased if there is a possibility of inherited blood-borne proteins that may have certain levels of abnormalities

Additional health problems

Subjective

The patient complaints of

· Extended periods of depression

· Lack of appetite

· Lack of energy

· A general feeling of loneliness

Objective

The objective diagnosis on the HEENT revealed levels of depression, no other objective diagnosis suggested depression

Assessment

Complaints of depression since his wife’s death three years ago, he does not appear to be suicidal but may require further psychiatric treatment. In the current state, the patient may use fluoxetine as a viable medication. The fact that the objective diagnosis has revealed that the patient has drug allergies means that fluoxetine may work better for the patient, as compared to other antidepressants.

Plan

Continue the therapy for six months while taking fluoxetine daily at doses of 20 mg once at noon or midnight. Engage more in social and physical activities. Monitor any signs of suicidal thoughts or changes in moods.

Risk Factors

· Sleep disorders

The patient currently complains of insomnia

· Serious illness

The current exposure to deep vein thrombosis may be a causative factor

· Lack of support system

The current level of loneliness is a causative factor

· Major life events

The death of the spouse

Plan

Deep Vein Thrombosis

· Use the warfarin anticoagulant, which prevents further formation of the blood clots (National Health Service, 2014)

· Advice on the use of compression stockings to reduce cases of getting the post-thrombotic syndrome

· Guide on the appropriate exercises after prescription on the compression stockings

· Advice on raising the affected leg to reduce any pressure in the veins

· Always consult your doctor before taking any complementary medication or therapy

· Frequent blood tests

· Health education:

· Stay hydrated by drinking plenty of water and avoiding alcoholic and caffeinated drinks

· Avoid smoking (active or passive)

· Engage in a sustainable weight-loss program

· Get regular exercises to keep fit

· Take more foods that are rich in Omega-3 fatty acids such as fatty fish

Referral: If the situation persists within the next few months, a referral to a vascular specialist will be necessary

Follow-up appointment: underlying medical conditions might lead to a recurrence of the DVT, which calls for a follow-up.

Depression

· Replace the over the counter antidepressants with fluoxetine 20 mg qd to be taken in the evening

· Monitor cases of anxiety or a headache

· Keep monitoring any changes in mood and interests in life

· Provide Naltrexone to counter the craving of alcohol, which is caused by loneliness and depression

· Health education:

· Have a strong support system

· Avoid stressful situations

· Encourage positive thoughts

· Engage in interesting activities

Referral: Refer to clinical psychologists for better therapeutic help