Ask Dr. Stephan Moll

These questions have been submitted by folks on the mailing list and answered by Dr. Moll, Director of the Thrombophilia Program at the Carolina Cardiovascular Biology Center, Department of Medicine, Division of Hematology-Oncology, UNC Chapel Hill (North Carolina, USA). Why am I doing this?

52. Questions to ask your doctor

Q: "When I had the clot in my leg I was so overwhelmed I just didn't know what questions to ask the doctor."

A: When you are seeing the doctor for the first time or in follow-up, it may be helpful to have the questions you have written down. Below are some suggestions as to what a patient may want to ask. The questions should not be interpreted as meaning that, for example, every patient with a blood clot should have all the laboratory tests done mentioned below, or should have a D-dimer test, Doppler ultrasound, or venogram. They are meant to serve as suggestions what you may want to discuss with your physician and on what topics you may want to hear his/her opinion.

1. If you have a newly diagnosed DVT or PE
   • Is it a superficial clot (= superficial thrombophlebitis) or a clot in the deep veins (= DVT)?
   • Is it a fresh (= acute) clot or an old one (=chronic)?
   • Is it a clot in the thigh or behind the knee (=proximal DVT) or in the calf veins (= distal DVT)?
   • If the DVT is only in the calf: are you going to give me blood thinners or do a f/u Doppler in a few days?
   • Could you give me a copy of the Doppler-ultrasound/VQ scan/spiral CT report that I can keep with my own medical records?
   • Should I get thrombolytic therapy (= "clot buster")?
   • What laboratory work-up for thrombophilia (=clotting disorders) will you do? Are you going to check me for
     • factor V Leiden?
     • prothrombin 20210 mutation?
     • homocysteine level?
     • anticardiolipin antibody titers?
     • lupus anticoagulant?
     • protein C and protein S deficiency? Are you ordering the activity or the antigen test or both?
     • antithrombin III deficiency? Are you ordering the activity or the antigen?
     • fibrinogen, factor 8, 9, or 11 levels?
   • If the doctor checks for factor V Leiden: Are you doing the genetic test or the APC resistance test?
   • What will you do to rule out a malignancy?
   • How long will I be treated with warfarin (=coumadin)?
   • What is my target INR?
   • Am I a candidate for low-dose warfarin (target INR 1.5-2.0) after an initial 6 months of full-dose warfarin (target INR 2.0-3.0)
   • What are your thoughts on generic warfarin versus brand coumadin?
   • Can I get a dietary consult to learn about vitamin K and warfarin (coumadin) interactions?
   • Should I wear a compression stocking?
   • Should the stocking be below or above the knee?
   • Where can you send me for an individually fitted compression stocking?
   • What should be my physical activity level in the next few weeks?
   • What are your thoughts on contraceptive options in me? What are your thoughts on progestin-only contraceptives?
   • What do I do if
     1. I think I may be pregnant,
     2. I know I am pregnant,
     3. I am planning pregnancy?
   • If you are found to have a laboratory abnormality (thrombophilia): Who in my family should also be tested?
   • Do you think I would benefit from seeing a thrombosis specialist?
   • Where is the nearest thrombosis specialist?
2. II. Questions to the doctor who will manage your warfarin (coumadin)
   • How many patients on warfarin (= coumadin) do you personally follow?
   • Do you use the PT (= prothrombin time) in seconds, the PT ratio, or the INR to monitor warfarin (= coumadin) therapy?
   • How does your office obtain blood for the INR: from an i.v. draw or a fingerstick?
   • How long does it take your office to get the results of my INR back and how long after the blood draw/fingerstick can I expect a phone call from your office regarding my INR and further warfarin (coumadin) dose?
   • Do you have a booklet where I can record my INRs and my warfarin (= coumadin) doses?
   • Is there an anticoagulation clinic close by in which my warfarin (= coumadin) management could be done?
   • Am I a good candidate to check my own INR at home with a home-monitoring device?
3. When you are having leg symptoms and think you might have a DVT
   • Would a D-dimer be helpful?
   • Should a Doppler ultrasound be done?
   • If the Doppler is negative: should a venogram be done?
4. When you are having chest pain or breathing problems and think you might have a PE
   • Would a D-dimer be helpful?
   • Should a VQ scan be done?
   • If a spiral CT is negative: should a VQ scan be done?
   • If the VQ scan or spiral CT is negative: should a pulmonary angiogram be done?

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