Part 4: Venous Thromboembolism

Elisabeth M. Battinelli, MD, PhD

Assistant Professor of Medicine, Harvard Medical School, Associate Physician, Division of Hematology, Brigham and Women's Hospital, Boston, MA

Jean M. Connors, MD

Assistant Professor of Medicine, Harvard Medical School, Medical Director, Anticoagulation Management Service, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA

Question 4

A 56-year-old man presents to the emergency room for sudden onset of shortness of breath and is determined to have an acute PE. His family history is significant for multiple relatives with colon cancer. The patient is a marathon runner and denies any recent period of immobilization, air travel, or illness. He states that he leads a very active lifestyle and that his shortness of breath came on suddenly. The patient asks about what might have caused him to have this thrombotic event. Since the patient has an acute thrombosis, the emergency room team explains that they will refer the patient to a hematologist for a hypercoagulable workup at a later time.

One month later, you see this patient in the hematology clinic and he again asks if he has any risk factors that led to this spontaneous thrombotic event. Which of the following is the most appropriate next step in the management of this patient?

  •   Explain that he is not obese, does not smoke, and leads a healthy
    lifestyle and therefore has no underlying risk for VTE
  •   Explain that because the patientís father has colon cancer and the
    patient has had a spontaneous clotting event, you are concerned that
    the patient may have an underlying malignancy. Ask the patient whether
    he has undergone age-appropriate cancer screening and question him on
    any symptoms that could suggest malignancy
  •   Explain that because the patient has a significant family history of
    malignancy and has had a spontaneous clotting event, you are concerned
    that he may have an underlying malignancy. Immediately send the patient
    for a full body CT scan to determine whether he has a malignancy
  •   Ask the patient to return when he completes his anticoagulation
    therapy to discuss his risk factors

Updated 11/21/2013 • jdw | Copyright ©2014 Turner White Communications