Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for mesenteric vein thrombosis (MVT)
(Specify) Abdominal pain (acute, severe, worsening)
May mention nausea, vomiting, diarrhea, bloody stools, abdominal distension
History of Present Illness:
Onset, duration, location, and severity of abdominal pain.
Associated symptoms (nausea, vomiting, diarrhea, bloody stools).
Changes in bowel habits (constipation or diarrhea).
History of abdominal surgeries, infections, or recent hospitalizations (risk factors).
Past Medical History:
Underlying conditions that increase MVT risk:
Hypercoagulable states (inherited or acquired)
Inflammatory bowel disease (IBD)
Abdominal malignancy
Recent abdominal surgery or trauma
Cirrhosis
History of deep vein thrombosis (DVT) or pulmonary embolism (PE)
Previous episodes of MVT.
Medications:
List all current medications, including any medications that may increase clotting risk (e.g., oral contraceptives, hormone replacement therapy).
Social History:
Smoking history (risk factor).
Recent immobility or hospitalization.
Family History:
Family history of blood clots (DVT, PE).
Physical Exam:
Vital signs: Assess for fever, tachycardia (rapid heart rate), hypotension (low blood pressure).
Abdominal examination:
Tenderness, guarding (involuntary muscle tensing), distention, ascites (fluid accumulation).
Bowel sounds (may be absent or high-pitched).
Rectal examination: May reveal blood in stool.
Laboratory Tests:
Complete blood count (CBC): May show elevated white blood cell count (WBC) suggestive of inflammation.
Basic metabolic panel (BMP): Assess electrolytes, kidney function, and liver function.
Coagulation studies: Evaluate for clotting abnormalities (e.g., PT, PTT, D-dimer).
Liver function tests (LFTs): May be abnormal in some cases of MVT.
Imaging Studies (as indicated):
Abdominal ultrasound: Initial imaging study to assess for signs of MVT (e.g., dilated veins, reduced blood flow).
CTA (computed tomography angiography) or MRA (magnetic resonance angiography): Definitive diagnostic tests for MVT, providing detailed images of the mesenteric veins and surrounding structures.
Angiography (traditional catheter angiography): May be used in specific cases for complex anatomy or prior to certain procedures.
Assessment:
Mesenteric vein thrombosis (suspected or confirmed): Based on clinical presentation, imaging findings, and consideration of alternative diagnoses.
Extent of thrombosis: Describe the location and extent of the blood clot within the mesenteric veins.
Severity of intestinal ischemia: Evaluate the degree of intestinal injury caused by impaired blood flow. This can range from mild to severe with potential for bowel infarction (tissue death) and bowel perforation.
Plan:
Urgent treatment is crucial to prevent complications:
Anticoagulation: Initiate anticoagulation therapy (blood thinners) to prevent further clot formation and extension. Heparin is typically used initially, followed by warfarin or newer oral anticoagulants for long-term management.
Thrombolysis (clot removal): In some cases, catheter-directed thrombolysis may be attempted to remove the clot, particularly if bowel viability is at risk.
Surgery: May be necessary for bowel resection (removal) if there is gangrene or perforation.
Vascular consultation: Urgent referral to a vascular surgeon for definitive diagnosis, treatment planning, and potential intervention.
Gastroenterology consultation: May be involved in managing intestinal ischemia and potential bowel complications.
Intensive care unit (ICU) admission: May be necessary for critically ill patients with severe intestinal ischemia or hemodynamic instability.
Follow-up:
Close monitoring in the acute phase to assess response to treatment and prevent complications.
Regular follow-up visits with imaging studies to monitor clot resolution and long-term management.
Investigation of underlying risk factors for MVT and potential preventive measures (e.g., compression stockings for patients at risk for DVT).
Education:
Educate the patient about MVT, symptoms, risk factors