Julie, a 50 yo female, was traveling on a transatlantic overnight flight returni
ID: 71494 • Letter: J
Question
Julie, a 50 yo female, was traveling on a transatlantic overnight flight returning home from a ski vacation in the Alps. She was sitting in coach next to a stranger. Not feeling like talking; she decided to take a sleeping pill, used her noise canceling headphones and an eye-mask and fell asleep. She slept through the night missing both meals and did not awaken until early the next morning when she felt the need to go to the bathroom. She felt very stiff from having sat in one position for so long and her legs felt heavy and “asleep” and “hot”. As she rose and made her way down the aisle to the bathroom she began to feel a sharp pain in her chest as if someone were stabbing her with a knife and the feeling of “a rope wrapped around her middle”. She also felt a dull burning, aching sensation especially when she tried to take a deep breath. Both arms were hurting and she felt discomfort in her neck, jaw and back. She began to feel short of breath and could feel her heart racing. She feel anxious and clammy and began to sweat. In just a few seconds she began to feel dizzy and light-headed and faint. After crying out for help she passed out and collapsed to the floor. The flight crew began CPR as the plane began to land. An ambulance met the plane and Julie was rushed to the hospital. Upon examination the following was charted:
Body temp: 100.1 F BP was 140/90
HR was 120
Respiration rate was 22 and extremely labored
Hemoptysis
No swelling of neck or lymph nodes
No apparent nausea or vomiting
Warmth,tenderness, swelling and redness of the lower left leg
Swollen wrists and ankles
Varicose veins on both legs
Recent bruises on both legs, one arm and abdomen
Anxiety
A field ECG was taken. The results are below.
1. What is your field diagnosis of Julie’s condition?
2. Why did she have a fever? Why was there swelling of the wrists and ankles?
3. What do Julie’s varicose veins have to do with his condition, if anything?
4. Did her behavior on the flight have anything to do with the incident? Sleeping medication? Missing meals? No water?
5. What life-threatening condition might Julie have been experiencing on the plane? What complications could have arisen if Julie had not received emergency medical attention?
6. Why did Julie feel chest pain and the collapse? At the hospital the doctor ordered the following tests: CBC ECG Chest x-ray CT and MRI Blood levels of Creatine Kinase Blood levels of D dimer Sonography—both cardio and venography Blood IgE levels Blood levels of Factor VIII, Factor IX and Factor XI were determined Full body examination Genetic analysis for V Leiden, Protein C, Protein S and Antithrombin III were performed
7. Why did the doctor order the tests he did? What conditions were ruled out? Julie was rushed into surgery for her condition. The doctor concluded that the surgery probably saved her life.
8. Establish a treatment plan for Julie—both in-hospital and later.
9. List any drugs that will be prescribed?
10. List any particular dangers or interactions she should be aware of?
11. What are the possible future complications that she might encounter? And why should Julie be very careful in the future? Is this condition likely to occur again?
12. Why is this both an acute and a chronic situation for Julie?
Once back home and recovered, Julie’s friend saw on television that taking a low-dose aspirin every day was useful in preventing heart attacks. She advised Julie that she should start a low-dose aspirin regimen to prevent something like this from happening again.
13. List the problems with Julie’s friend’s advice?
Explanation / Answer
1) The condition where a thrombus or clot forms in leg in deep vein is called as Deep Vein Thrombosis or DVT. Because of this clot people will have pain and swelling in led at the site of formation of clot. This problem becomes serious when the clot breaks and travels to the lungs. This condition is called as Pulmonary Embolus which causes severe injury to the body of person and death at times.
5) This occurs because of sitting for a longer period of time in pressure conditions. This causes swelling in ankles and at times causes deep vein thrombosis. This can occur in air travel, especially in economy class travel as the seats have less space to move and hence the person gets fixed and doesn’t move from one position to another for longer time. This causes slow movement of blood in the deep veins. This condition is sometimes called as “Economy Class Syndrome”. Hence, long hours of sitting in aircraft results in DVT problem.
6) Chest pain occured because of pulmonary embolism.
2)Symptoms of DVT include aching pain like in cramps, lower limb swelling, warmth or redness , fever because of inflammation and as a response by immune system to the given condition. When Pulmonary embolism occurs from DVT it causes severe breathlessness, chest pain, very high heart rate and blood coughing.
4) Dehydration for longer time increases the risk for traveler. Inside the aircraft, air is dry and dehydrates the passengers.
3)People with varicose vein problems are more susceptible to this problem. Although varicose veins don’t create any medical problem, only the veins get twisted, widened or bulged under the leg’s skin, those under the skin surface (superficial veins) and muscular veins(deep veins). DVT condition is far serious than the clot of blood in superficial veins. This clot can dislodge and migrate to brain, lungs or heart to cause death.
7) DVT can occur in people that have higher tendency for blood clotting. Blood test is performed to check the clotting time and different blood factors involved in blood clotting are measured to look for that factor that can promote clotting of blood. There are disorders that can be inherited like blood clotting factor deficiency like of Protein C. There can be defect in blood clotting factor like Factor V Leiden.
CBC: infection in blood
ECG: heart attack
Chest X-ray : condition of lungs, infection, fluid or infection
CT and MRI: to know the internal organs and blood movement.
Creatinine kinase: elevated in heart attack
Blood IgE : hypersensitivity reaction in blood because of external particle.
Hypersensitivity condition by IgE was ruled out. Heart attack was ruled out. Infection in lungs was ruled out.
D-Dimer test is recommended blood test to diagnose DVT that measures the essential blood clotting protein.
Commonly diagnostic test ultrasound scan is done to diagnose DVT which utilizes Doppler ultrasound.
To determine the location of blood clot Impedance Plethysmography (IPG) test is performed that measures the leg blood pressure at different locations in leg.
In case of Pulmonary Embolism a VQ scan is ordered. A special aerosol is inhaled by person along with injection of a special dye. Then X-rays are performed. Abnormality in X-ray will tell the Pulmonary embolism. Pulmonary angiography or CT scan can be used to diagnose pulmonary embolism also.
8) Treatment of DVT and Pulmonary embolism:
Movement of the clot has to be prevented immediately. Some clot s disappear themselves, for rest patient has to be admitted in hospital.
Anticoagulants: Blood thinning medicines are given to reduce the ability of blood to form clots. It can be taken in form of tablets like Ecospirin. Its doses can be modified regularly.
Thrombolytic agents: given intravenously to dissolve the formed clot. They have side-effects like causing severe bleeding resulting in large pulmonary embolus.
Surgery: People at high risk or those having severe or recurrent DVTs, surgery can be done on them to insert small filter to the main vein heading to the heart is recommended. This prevents blood clots moving to hearts and lungs.
LAter on Julie can take Aspirin low dosage at home for blood thinning.
9) Warfarin is taken along with regular blood tests so as to maintain regular amount in blood.
10)Little warfarin doesn’t prevent blood clot, and too much will cause bleeding. It can interact with vitamins (Vitamin K), foods and other substances. It is able to cause birth defects if taken in pregnancy.
11) Since Julie suffers from varicose veins, while travelling she should keep a little movement and should not stick to one place, resulting in slow movement of blood and increased susceptibility of blood clotting. She is at higher risk of DVT and she should take measure to reduce the risk by wearing compression stockings, taking medications for anticoagulation, exercises to increase blood flow in leg.
12) Julie is having varicose veins already so this is acute condition for her but incase she travels or sits for longer without exercise for long then this becomes chronic condition for her resulting DVT.
13) Ecospirin can be taken in low doses. but they have to be monitored continuosly as thinning of blood can result in bleeding inside the body and cause heamorrhage. Hence, blood thinning drugs have to be monitored with doctor.
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