Case 23 – update 2

Thanks for all of your comments so far.  We have decided that she has a high Well’s score and therefore does not need a d-dimer in diagnostic work up.  However having a baseline d-dimer may be useful in later stages as d-dimers are used in some haemostasis clinics as a mean to help decision making when attempting to stop anticoagulation at a later stage.  Thrombophilia screening is debatable at this stage but for tests that use functional assays the result may not be accurate during an acute thrombotic event.

Back to our patient… she has an ultrasound with colour doppler of the proximal veins which confirms a deep vein thrombosis.  She is started on low molecular weight heparin.  She states that she has no bleeding problems except that she has noticed heavy menstrual bleeding in between cycles and following intercourse.

It is important to look for risk factors for DVT:

  • Malignancy
  • Inherited thrombophilia
  • Surgery/immobility/cast
  • Antiphospholipid syndrome
  • Myeloproilferative neoplasms
  • Autoimmune disease and inflammatory states (increased VIII)
  • Systemic illness
  • Pregnancy
  • Oestrogen therapy
  • Provoking drugs – thalidomide, asparaginase, tamoxifen

Blood tests reveal:

  • Hb 92g/L, MCV 75fL, WCC 12.2×10*9/L (neutrophilia), platlets 475×10*9/L
  • U&E – normal, LFT – normal, ferritin 7mcg/L, CRP 12, bHCG -ve

Questions:

  • What investigations do you perform next?
  • Is it safe to commence anticoagulation?

Please reply on Twitter and always include #teamhaem to allow others to follow your comments. Please join in the debate and learn about haematological problems along the way. The case will continue to  evolve over the coming week so keep checking #teamhaem for more information.

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