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Braun and Anderson, Chapter 16 Case Studies Case Study 16-1 James is a 55-year-old male who presents in the Emergency Department (ED) with sudden swelling in his left leg. He is complaining of a dull ache in his calf that increases when he is walking. He states, “My left leg feels really tight and hot.” He works as a truck driver and has just finished a long route that lasted 10 days. He does admit to an injury to his lower leg about 2 weeks ago, but he thought that the injury was resolved. He does not exercise regularly. He is a smoker. He reports no other significant health history. After physical examination, he undergoes a Doppler compression ultrasound, and a deep vein thrombosis (DVT) is detected. 1. Outline the process that is most likely occurring in this man’s body. Answer: In a DVT, a clot has occurred in a vein precipitated by endothelial injury, hypercoagulability, and/or venous stasis. His risk factors are the history of vascular wall injury, immobility related to his employment, smoking, and lack of physical activity. A blood clot forms in the vein causing obstruction and pain. 2. What would you expect for clinical manifestations? Answer: A common site for DVT is the leg. Clinical manifestations include swelling, tightness, discomfort (dull ache), and increased discomfort with ambulation, redness, and heat. 3. What diagnostic tests could be used? Answer: Venography, Doppler compression ultrasonography, or impedance plethysmography. Blood tests that detect high levels of substances that degrade fibrin may be used. 4. What treatment measures and complications would you anticipate? Answer: Once DVT is diagnosed, anticoagulant therapy is often initiated to prevent new or expanded clots from forming. If migration of the clot is anticipated, a filter into the inferior vena cava may be placed to catch the emboli and thrombolytic agents may be used. Surgical removal of the thrombus is another potential treatment option. The greatest complication is that of a pulmonary embolus.

Braun & Anderson: Applied Pathophysiology 3e, Chapter 16 © Wolters Kluwer

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Case Study 16.2 Jamie is a 15-year-old female who has concerns about excessive bleeding with her last menstrual period. She has noticed recently that she bruises easily and bleeds readily, particularly with her gums while brushing her teeth. She also has had nosebleeds recently. She comes into your clinic for examination. You note nonpalpable petechiae of her legs and arms, purpura, and gingival bleeding. Her platelet count is less than 20,000/mm3. She is diagnosed with idiopathic thrombocytopenic purpura (ITP). 1. Outline the process that is most likely occurring in this adolescent’s body. Answer: ITP, also known as primary immune thrombocytopenic purpura and autoimmune thrombocytopenic purpura, is defined as isolated thrombocytopenia with normal bone marrow and the absence of other causes of thrombocytopenia. The two distinct clinical syndromes manifest as an acute condition in children and a chronic condition in adults. ITP is a decrease in the number of circulating platelets in the absence of toxic exposure or a disease associated with a low platelet count. ITP is primarily a disease of increased peripheral platelet destruction, with most patients having antibodies to specific platelet membrane glycoproteins. Relative marrow failure may contribute to this condition, since studies show that most patients have either normal or diminished platelet production. Acute ITP often follows an acute infection and has a spontaneous resolution within 2 months. Chronic ITP persists longer than 6 months without a specific cause. 2. What would you expect for clinical manifestations? Answer: Common signs, symptoms, precipitating factors, and physical findings include the following: a. Abrupt onset (childhood ITP) b. Gradual onset (adult ITP) c. Purpura d. Menorrhagia e. Epistaxis f. Gingival bleeding g. Recent live virus immunization (childhood ITP) h. Recent viral illness (childhood ITP) i. Bruising tendency j. Nonpalpable petechiae, which mostly occur in dependent regions k. Hemorrhagic bullae on mucous membranes l. Purpura m. Gingival bleeding n. Signs of GI bleeding o. Menometrorrhagia, menorrhagia p. Retinal hemorrhages q. Evidence of intracranial hemorrhage, with possible neurologic symptoms

Braun & Anderson: Applied Pathophysiology 3e, Chapter 16 © Wolters Kluwer

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r. Nonpalpable spleen: The prevalence of palpable spleen in patients with ITP is approximately the same as that in the non-ITP population (i.e., 3% in adults, 12% in children). s. Spontaneous bleeding when platelet count is less than 20,000/mm3 3. What diagnostic tests could be used? Answer: Laboratory Studies  CBC  Isolated thrombocytopenia is the key finding regarding laboratory evaluation.  Truly giant platelets on peripheral smear suggest congenital thrombocytopenia.  The WBC count and hemoglobin typically are normal, unless severe hemorrhage has occurred.  Coagulation studies are normal, and a bleeding time is not useful. Imaging Studies  A CT scan of the head is warranted if concern exists regarding intracranial hemorrhage. 4. What treatment measures and complications would you anticipate? Answer:  Life-threatening bleeding requires conventional critical care interventions.  In the patient with known ITP, high-dose parenteral glucocorticoids and IV immunoglobulin (IVIg), with or without platelet transfusions, are appropriate.  Platelet transfusion is indicated for controlling severe hemorrhage. Send a blood specimen to the lab for type and screen in case platelet transfusion is necessary.  Splenectomy is reserved for patients in whom medical therapy fails.  Clinical trials have shown promise for agents that directly stimulate platelet production, such as thrombopoietin (TPO) receptor-binding agents. While they show promise for raising platelet counts, there are potential safety concerns such as thrombocytosis and rebound thrombocytopenia. Hemorrhage represents the most serious complication; intracranial hemorrhage is the most significant. The mortality rate from hemorrhage is approximately 1% in children and 5% in adults. Log on to the Internet. Search for a relevant journal article or Web site (such as http://emedicine.medscape.com/article/779545-overview) that details idiopathic thrombocytopenic purpura and confirm your predictions.

Braun & Anderson: Applied Pathophysiology 3e, Chapter 16 © Wolters Kluwer

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