From the Guidelines
The patient should resume regular Tylenol 650-1000 mg every 6 hours as needed for pain, and apply warm compresses to the surgical site three times daily for 15 minutes to help reduce induration, while continuing Eliquis as prescribed. The patient presents to the ED with post-operative pain following a thrombectomy for pulmonary embolism removal, and has a 0.5 cm surgical wound on his left groin with approximately 1 cm of hardening around the site. He reports pain when walking and hardening at the incision site, and has not taken Tylenol since yesterday. He denies fever, chills, shortness of breath, nausea, vomiting, and dizziness, but reports some cough with mucus since the procedure.
Subjective
- Patient reports post-operative pain at the left groin thrombectomy site, particularly when walking
- He describes hardening around the incision site and has not taken Tylenol since yesterday
- He reports a productive cough since the procedure but denies fever, chills, shortness of breath, nausea, vomiting, or dizziness
Objective
- Vital signs stable
- Left groin shows a 0.5 cm surgical wound with approximately 1 cm of induration around it
- The area is tender to palpation but without erythema, purulent discharge, or active bleeding
- CBC shows RBC 4.32, hemoglobin 13.1, hematocrit 39.4
- CMP shows glucose 128, chloride 112, with other values within normal limits
- Currently on Eliquis anticoagulation therapy
Assessment
- Post-operative pain and localized induration following thrombectomy, likely representing normal post-surgical inflammation rather than infection, as suggested by the guidelines for postoperative pain management in non-traumatic emergency general surgery 1
- Productive cough likely related to post-procedural irritation
- The patient's anticoagulation therapy with Eliquis should be continued as prescribed, taking into account the guidelines for the management of patients with atrial fibrillation 1
Plan
- Resume regular Tylenol 650-1000 mg every 6 hours as needed for pain
- Apply warm compresses to the surgical site three times daily for 15 minutes to help reduce induration
- Continue Eliquis as prescribed
- Follow up with vascular surgery in one week or sooner if symptoms worsen
- Return to ED if fever develops, wound drainage occurs, pain significantly increases, or if redness extends beyond current area
- Monitor cough; return if worsens or if shortness of breath develops, as postoperative pain syndrome can lead to respiratory complications 1
From the Research
Subjective
- The patient is a 76-year-old male presenting to the ED with complaints of post-op pain after a thrombectomy for PE removal.
- He reports pain when walking and hardening on the incision site, which is approximately 0.5cm on the left groin.
- The patient denies fever, chills, shortness of breath, nausea, vomiting, and dizziness.
- He reports some cough with mucus since the procedure.
Objective
- Physical assessment reveals about 1cm of hardening around the surgical site with some tenderness, but no signs of infection or bleeding.
- Laboratory results show:
- CBC: RBC 4.32, hemoglobin 13.1, hematocrit 39.4.
- CMP: glucose 128, chloride 112, otherwise unremarkable.
- The patient is currently on Eliquis (apixaban) 2, 3, 4.
Assessment
- The patient's symptoms and laboratory results suggest that he is experiencing post-op pain and possible wound hardening, but no signs of infection or bleeding.
- The use of apixaban (Eliquis) is appropriate for the treatment and prevention of recurrent DVT and PE 2, 3.
- However, the patient's age (>75 years) is a consideration, as there is limited data on the use of apixaban in this population 2.
Plan
- Manage the patient's post-op pain with acetaminophen or NSAIDs, as recommended for acute mild to moderate pain 5.
- Consider the use of adjunctive medications or alternative treatments if the patient's pain is not adequately controlled.
- Continue to monitor the patient's condition and adjust the treatment plan as needed, taking into account the patient's age and medical history.
- Consider the use of "as-needed" range orders for opioid analgesics, if necessary, with careful monitoring and evaluation of the patient's response to treatment 6.