How hard is it to think there is a systemic approach where you illuminate guessing and you construct your work surely, seems like many of you works for GE There is cost ,waiting list, time table ,other health concern , you can't just ask for imaging whenever you want like if it a fax machine. And if someone think I'm wrong, prove it, I don't mind to be wrong at all. Actually I appreciate it in advance
Fairly spot on. Sometimes a high enough pre test probability precludes d-dimer testing and they jump straight to imaging and treatment. In Bosh's case, a D-Dimer wouldn't matter because he would be getting an ultrasound of the legs anyway. I am sure they also gave him a CTA chest as well because of his VIP status.
Actually, I stated different approaches to different cases can vary. In CB case D-Dimer won't even work since he already started on blood thinner
Even with therapeutic anticoagulation, the thrombus remains. It just starts to dissolve because the equilibrium is shifted to clot dissolution. D-Dimer is still elevated post initiation of treatment. Hell D-Dimer is elevated if you have the flu. D-Dimer should go to normal levels a month past cessation of therapy, and many will not initiate life long anticoagulation based on persistently elevated D-dimer without other clinical indications (e.g. Pulmonary hypertension or PTS)
Correct. D-dimer has relatively poor specificity but high sensitivity, which is the bulk of its clinical value. The historic gold standard for diagnosing DVT/PE is angiography or venography. However, we now use CT PE studies and ultrasound as first line diagnostic tests. Whether or not you start heparin due to high suspicion of VTE would depend on risk/benefit ratio of therapy and the accessibility of these diagnostic studies, including potential contraindications.
RF? DM = Diabetes? Yes. Diabetics can get medical imaging as needed. Yes pregnant patients can and do get medical imaging. Example: your pregnant friend has sudden pelvic pain.
Correct by how is that is different from what i said previously . Even MD is just rephrasing the exact same thing
You are talking in circles. First you say anticoagulation tests can diagnose a DVT. Then you say medical imaging plays a secondary role in diagnosis. Then you say the patient won't have an elevated D-Dimer* because he is on therapy. Now you're saying you've been saying what MD and I have been posting all along.
RF :Renal failure . So it's exactly what Welles score is about to calculate the risks. It's do-able but with caution-preparation* and related risks *IV fluid /Bicarb before scan. For you other remarks , Anticoagulation test used to diagnose the CAUSE for The clot ( genetic,lupus etc; Medical imaging is the golden diagnostic test that POINT OUT the blood clot but comes with Risks . About circles talks , I really didn't expect to go into details for basics stuffs or that I had to re-explain the obvious
I caught on after a couple of posts. This is typical Exiled, the dude is insane. Read his posts in the D&D, you will be going on and on in circles arguing about nothing.
lol hematologists have it pretty good. I'm a pulmonologist and I deal with this on a daily basis. I'll make it simple for you because it's really simple. D-Dimer is only useful in low risk folks. Maybe that was Bosh the first time. I don't know what they did to work him up. But as I recall he was having chest pain and conditioning issues. So they probably started with imaging (CT, ultrasound) and found the clot and I believe they did not find a DVT as it had already migrated. Ok, first time, 6 months anticoagulation. We'll work you up for genetic causes, as this was unprovoked. A recent study showed that cancer surveillance isn't indicated in the absence of targeted symptoms. Check for genetic causes, maybe look for anatomical abnormalities of the venous system, probably won't happen again. Check an echo, make sure his heart is OK (no pulmonary hypertension) and that he doesn't have any cardiac defects that put him at risk for a systemic embolus. He was probably on one of the new anticoagulants where you don't need to check frequent blood tests to know if you dosed them right. Ok, it happens a second time, D-Dimer isn't helpful now because you're at intermediate or high risk and hell for all the reasons stated above its a useless test except in low risk people who have no medical history and you don't really think they have it anyway. As one of my mentors said, why did you check D-Dimer? Because the lab was open. Now he has calf pain. Ok, we start with an ultrasound because we are worried. You don't have to do a CT here but I'm sure they did. Maybe the CT is negative but he has a below the knee clot. OK. The guidelines for first-time superficial DVT suggest no treatment unless the clot persists. But this is his second time. The guideline for a second DVT or PE indicate lifetime anticoagulation. But this is a low-risk DVT. So he's in a gray area where the risk of PE is low but non-zero. So this is why the answer is unclear. But the SCIENCE is simple.
Thanks at least you did't re-start "medical terminology "copy paste war exchange , seems like everyone not named Chris Bosh has a very good medical opinion I was under the wrong impression ,this won't turn to be ,the fishy "im the real Internet Doc.", so I am glad you took step by step approach as well I work closely with hematologists specially on NS tumours. I only play hematologist on stat.Days .( and some consultant must show physically if needed on.calls BTW). I'm aware there is a variety of opinion based on different interpretation but not based on the approach since thing nearly systemic so to speak and yes sup-specialist can be your best friend in many situation , D dime accuracy and the famous flu talk not usually discussed at least in depth since practically you ask the patient : hey did you sneeze recently ,tell me more about your typical green veggie intake and what about your other medication ,any illegal drug just pass it to me..etc;. Back to your initial reply" lol you make it sound like rockets science ..its 3 options of treatment really....." This what common practice would be to any patient . As for Chris case, it's an alarming ,if I were him I would seek 2nd ,3rd opinion. No reason the 2nd clot caught him by a surprise ,or a pause of medical monitoring and check up. Here is the rockets science stuff: A flight from Miami to LA for example is 5:44 on commercial direct root trip. Or nearly 5 hours on 727 private jet. More than 45trip a year for business alone ,top that with personal trips and diving, swimming and other physical activities .so an additional heparin would be needed . This why I said : custom made medication dosage is a must , evaluate the case from the beginning
<blockquote class="twitter-tweet" data-lang="en"><p lang="en" dir="ltr">Heat once again say there will be no update on Chris Bosh today.</p>— Ira Winderman (@IraHeatBeat) <a href="https://twitter.com/IraHeatBeat/status/702529379381997568">February 24, 2016</a></blockquote> <script async src="//platform.twitter.com/widgets.js" charset="utf-8"></script>
