Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation and management of suspected catheter-related thrombosis (CRT).
SOAP
Subjective (S):
Symptoms:
Inquire about any recent symptoms suggestive of CRT, depending on the location of the catheter:
Central venous catheter (CVC): New or worsening chest pain, shortness of breath, cough, arm swelling on the side of the catheter insertion.
Dialysis catheter: Leg swelling, pain, redness, or tenderness in the leg with the catheter.
Peripherally inserted central catheter (PICC): Arm swelling, pain, redness, or tenderness along the vein where the PICC is placed.
Catheter History:
Investigate the type of catheter (CVC, PICC, dialysis catheter) and duration of placement.
Explore for any recent manipulations or changes to the catheter.
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying conditions that might increase susceptibility to CRT (e.g., hypercoagulable states, malignancy, recent surgery)
Previous episodes of thrombosis or pulmonary embolism (PE)
Risk factors for thrombosis (e.g., prolonged immobilization, smoking)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for:
Signs of deep vein thrombosis (DVT) in the extremity with the catheter (if applicable):
Homan’s sign (pain with dorsiflexion of the foot)
Swelling
Erythema (redness)
Increased skin temperature
Signs of PE (if suspected):
Dyspnea (shortness of breath)
Pleural effusion (fluid around the lungs) on chest exam
Tachycardia (rapid heart rate)
Signs of superior vena cava syndrome (if involving a CVC):
Facial swelling
Neck vein distention
Difficulty breathing
Assess for catheter insertion site redness, swelling, or tenderness.
Assessment (A):
Clinical Diagnosis:
Based on clinical presentation, risk factors, and suspicion for DVT or PE, establish a working diagnosis of suspected CRT.
Specify the suspected location of the thrombus (e.g., DVT in the arm or leg with PICC or dialysis catheter, PE if suspected).
Catheter-related:
Emphasize that the thrombosis is likely catheter-related based on the presence of a catheter.
Plan (P):
Imaging Studies:
Order appropriate imaging studies to confirm CRT diagnosis:
Doppler ultrasound: Non-invasive test to assess for blood flow and clots in the veins.
Venography (if indicated): X-ray using contrast dye to visualize veins and confirm a clot.
Ventilation-perfusion (V/Q) scan or CT angiogram (if PE suspected): Imaging studies to diagnose PE.
Anticoagulation Therapy:
Initiate anticoagulation therapy based on the severity of CRT and bleeding risk:
Unfractionated heparin or low-molecular-weight heparin (LMWH): Initially to prevent further clot growth and embolization.
Warfarin or other oral anticoagulants: Long-term therapy to prevent new clot formation.
Catheter Management:
Catheter removal: Depending on the severity of CRT and the ability to establish alternative vascular access, consider prompt removal of the catheter to eliminate the source of thrombus formation.
Catheter salvage (if applicable): If catheter removal is not feasible, emphasize the importance of aseptic technique during manipulation and meticulous catheter care to prevent further complications.
Supportive Care:
Provide supportive measures as needed, such as leg elevation for DVT or oxygen therapy for PE.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., hematologist, vascular surgeon)
Need for additional testing (e.g., blood tests for hypercoagulable state)
Implementation of preventive measures to reduce future CRT risk (e.g., increased mobility, hydration)
Patient education regarding the importance of signs/symptoms of CRT and adherence to anticoagulation therapy