What is the best approach to manage a male patient with hypertension, morbid obesity, chronic kidney disease stage 2, lack of coordination, low back pain, and chronic gout, diagnosed with acute embolism and thrombosis of the left femoral vein, presenting with left leg swelling and low back pain?

Case Management Recommendations for Acute Left Femoral Vein Thrombosis with Multiple Comorbidities

Immediate Priorities

Continue rivaroxaban anticoagulation indefinitely and arrange urgent vascular surgery consultation to evaluate for catheter-directed thrombolysis or mechanical thrombectomy, as the patient has acute iliofemoral DVT with significant limb swelling that has progressed from calf to thigh. 1

Anticoagulation Management

• Rivaroxaban should be continued at therapeutic dose (15 mg twice daily for 21 days, then 20 mg once daily) as the patient is already on this medication 1
• Duration of anticoagulation must be at least 3 months minimum, but given the extensive iliofemoral involvement and lack of clear reversible risk factor, indefinite anticoagulation is recommended 1
• The patient's chronic kidney disease stage 2 does not contraindicate rivaroxaban use, though renal function should be monitored regularly 1

Urgent Vascular Intervention Consideration

The patient requires immediate vascular surgery evaluation because left-sided iliofemoral DVT raises suspicion for May-Thurner syndrome (iliac vein compression), which has higher recurrence rates with anticoagulation alone. 1

• Catheter-directed thrombolysis (CDT) or percutaneous mechanical thrombectomy (PMT) with possible iliac vein stenting should be considered, as recurrent VTE occurs more frequently with anticoagulation alone in patients with underlying iliac vein compression 1
• The general consensus is to treat iliac vein obstructive lesions with stents in addition to anticoagulation, despite lack of rigorous randomized controlled trials 1
• The patient's statement that he is "awaiting surgery to remove the blood clot" suggests this has already been discussed, but case management must ensure this consultation is expedited 1

Critical Safety Instructions

The patient was correctly advised NOT to massage the left leg while the active blood clot is present, as this could dislodge the thrombus and cause pulmonary embolism. 1

• Compression stocking application is appropriate for symptom management, though recent trials show no specific benefit in preventing post-thrombotic syndrome 1
• Leg elevation should be encouraged in addition to compression therapy for patient comfort 1

Transportation and Social Support Coordination

Case management must immediately arrange reliable medical transportation for the patient's vascular surgery consultation and any required interventional procedures. 1

• The patient explicitly stated he needs reliable transportation to medical appointments—this is a critical barrier to care that must be addressed urgently
• Given the acute nature of iliofemoral DVT and risk of pulmonary embolism, delays in accessing care could be life-threatening 1
• Consider arranging non-emergency medical transportation through insurance or community resources

Homemaker Services Assessment

• The patient reports his weekend homemaker is "not helpful"—case management should assess what specific assistance he needs (medication management, meal preparation, mobility assistance, wound care monitoring)
• Given his morbid obesity, lack of coordination, and current acute DVT with 2+ pitting edema, he likely requires assistance with activities of daily living
• Consider increasing homemaker hours or changing providers if current services are inadequate

Cardiovascular Risk Optimization

This patient is at extremely high cardiovascular risk given his combination of hypertension, morbid obesity, chronic kidney disease, and now acute venous thromboembolism. 1

Blood Pressure Management

• Current BP of 131/94 mmHg is above target for a patient with CKD and diabetes (implied by Jardiance and insulin use) 1
• Target blood pressure should be <130/80 mmHg 1, 2
• Losartan is appropriate as it provides renal protection in CKD, but dose optimization may be needed 3, 4

Lipid Management

• Atorvastatin should be optimized to achieve LDL-C target <55 mg/dL given his high cardiovascular risk 2
• Case management should ensure lipid panel is checked and statin dose adjusted accordingly

Diabetes Management

• The patient is on Jardiance (empagliflozin), metformin, and insulin—HbA1c target should be <7% 2
• Strict glycemic control is associated with improved outcomes in patients with vascular disease 2
• Case management should verify recent HbA1c and ensure diabetes follow-up is scheduled

Pain Management Concerns

The patient reports 8/10 low back pain attributed to "slipped disc" and is on multiple pain medications (Tylenol, gabapentin, lidocaine patch, Motrin, tramadol). 5

Medication Safety Review

• The combination of Motrin (ibuprofen) with rivaroxaban significantly increases bleeding risk—this should be reviewed urgently 1
• NSAIDs should generally be avoided in patients on anticoagulation and with CKD stage 2 1, 5
• Alternative pain management strategies should be explored (physical therapy, weight reduction, non-NSAID analgesics)
• Gabapentin is listed twice in the medication list—verify if this is a documentation error or actual duplication

Gout Management

Allopurinol is appropriate for chronic gout management, particularly in a patient with CKD, hypertension, and cardiovascular disease. 5

• Gout is commonly associated with obesity, diabetes, hypertension, chronic kidney disease, and thromboembolic disorders—all present in this patient 5
• Ensure uric acid levels are monitored and allopurinol dose is appropriate for renal function
• Acute gout flares should be managed with colchicine rather than NSAIDs given his anticoagulation and CKD 5

Weight Management Strategy

Morbid obesity is the central driver of this patient's hypertension, CKD progression, and likely contributed to his DVT risk. 3, 4, 6

• Obesity increases renal sodium reabsorption, activates the sympathetic nervous system and renin-angiotensin-aldosterone system, and causes physical compression of the kidneys 3, 4
• Visceral and perirenal fat compression contributes to both hypertension and renal dysfunction 4, 6
• Case management should arrange referral to weight management program or bariatric surgery evaluation, as medical therapy alone is often insufficient 4, 6
• Jardiance (empagliflozin) provides some weight loss benefit in addition to cardiovascular and renal protection

Monitoring and Follow-Up Schedule

Immediate (Within 1 Week)

• Vascular surgery consultation for possible CDT/PMT with stenting 1
• Arrange reliable transportation for all medical appointments
• Review and modify pain medication regimen to eliminate NSAID use 1
• Assess and address inadequate homemaker services

Short-Term (2-4 Weeks)

• Recheck renal function (creatinine, eGFR) given CKD and anticoagulation 1
• Monitor for signs of bleeding or DVT progression 1
• Verify compression stocking compliance and assess leg swelling improvement 1
• Check HbA1c and lipid panel 2

Long-Term (3-6 Months)

• Reassess duration of anticoagulation at 3 months—likely indefinite given iliofemoral location and possible May-Thurner syndrome 1
• Monitor for post-thrombotic syndrome development 1
• Evaluate weight loss progress and consider bariatric surgery referral if medical management fails 4, 6
• Optimize blood pressure control to target <130/80 mmHg 1, 2

Red Flags Requiring Immediate Emergency Department Referral

• New onset chest pain, shortness of breath, or hemoptysis (pulmonary embolism) 1
• Sudden worsening of leg pain, coldness, or development of motor weakness (acute limb ischemia) 2
• Any bleeding complications (hematuria, melena, hematemesis, intracranial hemorrhage symptoms) 1
• Fever with leg warmth/erythema (possible septic thrombophlebitis) 1

Documentation for Case Management

• Patient is evasive with case management check-ins—establish clear communication plan and document all contact attempts
• Address barriers to engagement: transportation, inadequate home services, pain management
• Consider social work referral for comprehensive needs assessment
• Document patient's understanding of anticoagulation risks, leg massage prohibition, and warning signs requiring emergency care 1