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A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
A Case of DVT for Discussion
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A Case of DVT for Discussion

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  • 1. A CASE OF DEEP VEIN THROMBOSIS FOR DISCUSSION PROF. P. VIJAYARAGHAVAN’S UNIT Dr.P.ARUL P.G.
  • 2.
    • 45 years old Mrs. Ammakanu was admitted with chief complaints of Left leg swelling 30 days right sided abdominal pain 20 days and breathlessness 4 days
  • 3.
    • History of presenting illness:
    • Patient apparently normal before 30 days. developed left leg swelling and pain. she was admitted in a private hospital, following treatment the swelling and pain subsided. Later she had abdomen pain–dull aching, more over the right hypochondrium, no aggravating or relieving factors.
    • Breathlessness present for past 4 days grade 3 initially and now grade 4.
    • H/o orthopnea+
    • H/o vomiting once
    • No h/o fever or headache.
    • No h/o chest pain or palpitation.
  • 4.
    • No h/o cough
    • No trauma
    • No h/o altered bladder or bowel habits.
    • No h/o altered sensorium.
    • Past history:
    • h/o arthritis for which she takes NSAIDS
    • Not a diabetic or hypertensive or asthmatic or epileptic or tuberculous patient
  • 5.
    • Treatment history:
    • Patient was started on warfarin 15 days back in a private hospital.
    • Personal history : Takes mixed diet. Not an alcoholic or tobacco chewer. Regular 3/30 days menstrual cycle. H/o 3 spontaneous abortions +, 2 live children.
    • Family history : No similar illness in the family.
    • Contact history :
    • No history of contact with patients with tuberculosis.
  • 6.
    • General examination
    • Pt conscious, oriented, afebrile,
    • dyspneic, tachypneic
    • pallor+, malar rash +
    • no icterus/cyanosis/clubbing
    • no significant lymphadenopathy
    • bilateral pitting pedal edema
    • generalised swelling of the left lower limb
    • JVP raised
  • 7.
    • Vital signs:
    • Bp 110/60mm hg
    • Pulse 76/min
    • RR 24/min
    • Temperature 98.4 F
  • 8.
    • EXAMINATION OF CVS:
    • S1 S2 heard but muffled
    • RV-S3 heard
    • EXAMINATION OF RS;
    • NVBS+ . no added sounds.
    • EXAMINATION OF ABDOMEN:
    • Soft ,bowel sounds heard, liver enlarged 7X3.5 cms size, soft, tender .
    • EXAMINATION OF CNS:
    • No FND.
  • 9.
    • EXAMINATION OF THE LEFT LL:
      • Limb is swollen through out, tender, dusky appearance.
      • Peripheral pulses felt.
  • 10.
    • INVESTIGATIONS
    • RBC 3.11million
    • WBC TC 4000
    • DC p-77%,L-13%,E-10%
    • Platelet 80,000
    • PCV-30
    • MCV83.0
    • MCH 25.3
    • MCHC 30.5
    • HB-9.4 gm%
    • ESR 36mm.
    • Blood group A+
    • PT control 12-15 sec, test 38
    • APTT control 26.test 38
    • INR 2.2
  • 11.
    • Blood sugar-141gms/dl
    • Urea-43
    • Creatinine-1.1
    • LIVER FUNCTION TEST
    • Total bilirubin 5.4
    • Direct 4.3
    • AST-87.1
    • ALT-242
    • GGT-35
    • SAP-254
    • Total protein 6.8
    • Alb 3.1
    • Globulin 3.7
  • 12.
    • S.electrolytes
    • Sodium 138
    • Potassium-4.07
    • Chloride-102.5
    • HIV-NEGATIVE
    • HBSag NEGATIVE
    • Anti Hb c NEGATIVE
    • Urine colour yellow
    • appearance clear
    • ph 6.5
    • sp.gravity 1.025
    • Alb-nil
    • Sugar-nil
  • 13.
    • Nitrites –negative
    • Leucocytes 8to 10 hpf
    • Epithelial cells –occasional
    • Rbc-2-3/hpf
    • Cxr- cardiomegaly
    • ECG- sinus tachycardia, poor prognosis of r wave
    • Urine c&s-no growth
    • ANA (homogenous) +
    • LUPUS ANTICOAGULANT +
    • ACL ANTIBODY –NEGATIVE.
  • 14.  
  • 15.  
  • 16.  
  • 17.  
  • 18.
    • Echo
    • Pericardial effusion+
    • Fibrous strands+
    • RA collapse+
    • Normal lv systolic function
    • Mild diastolic dysfunction
    • Mild hypokinesia of IVS AND LV APEX
    • No evidence of tamponade
    • Normal chamber dimension,
    • Doppler study
    • Left popliteal vein thrombosis extending into superficial femoral vein.
  • 19.
    • Ultra sound abdomen
    • Minimal free fluid in morrison pouch
    • Hepatomegaly
    • Minimal ascites
    • Left pleural effusion
    • Pericardial effusion
  • 20.
    • Hematologist and rheumatologist opinion
    • ?APLAS
    • Vascular surgeon opinion – DVT Left LL
    • Elastocrepe bandage, leg elevation, tablet folic acid, in view of jaundice and abnormal PT and INR Heparin therapy is deferred.
    • Cardiologist opinion to start acitrom
  • 21. DIAGNOSIS
    • A Case of DVT left lower limb probably due to hyper coagulable state (anti phospholipid antibody syndrome secondary to SLE) with pericardial effusion, pleural effusion, ascites due to polyserositis.
  • 22.  
  • 23. DIAGNOSIS – ARA CRITERIA
    • Malar rash
    • Discoid rash
    • photosensitivity
    • Oral ulcers
    • Arthritis
    • Serositis
    • Renal disorder
    • Neurological disorder
    • Hematological disorder
    • Imm. disorder
    • Antinuclear Abs
    • 4 or >likely to be SLE
  • 24.  
  • 25.
    • DEEP VEIN THROMBOSIS
    • Commonly affects-leg veins or deep veins of pelvis.
    • Causes and risk factors:
    • Conditions that cause compression of veins, physical trauma, cancer, infections , certain inflammatory diseases, specific conditions like stroke, heart failure and nephrotic syndrome.
  • 26.
    • Surgery, hospitalisation, Immobilisation, smoking,obesity, drugs like estrogens, erythropoietin and diseases like thrombophilia.
    • Women have risk during pregnancy and postnatal period,
    • Air travel
    • May thurner syndrome
  • 27.
    • MECHANISM -VIRCHOWS TRIAD
    • Decreased flow rate of blood,
    • Damage of blood vessel,
    • Increased tendency of blood to clot
  • 28.
    • SYMPTOMS AND SIGNS
    • No symptoms sometime
    • Pain,swelling and redness of leg
    • Superficial veins may enlarge.
  • 29.
    • COMPLICATIONS
    • Pulmonary embolism
    • Post phlebitic syndrome
    • INVESTIGATIONS
    • Gold standard test-IV venography.
    • Physical examination
    • Homans test
    • Pratts sign
  • 30.
    • Wells score
    • Active cancer-1point
    • Calf swelling>3cms-1pt
    • Collateral veins-1pt
    • Pitting edema-1pt
    • Swelling of entire leg-1pt
  • 31.
    • Localised pain along distribution of deep venous system-1pt
    • Paralysis,paresis or recent immobilisation of leg-1pt
    • Recently bedridden or surgeryor pts requirina GA-1pt
    • INTERPRATATION.
    • 2 OR > PTS-DVT LIKELY
    • <2 DVT UNLIKELY
    • BLOOD TEST
    • D-DIMER TEST
  • 32.
    • OTHER TESTS
    • CBC, pt APTT, fibrinogen, liver enzymes, renal function test and electrolytes
    • Imaging leg veins
    • Impedance plythesmography
    • Doppler ultra sonogram
  • 33. TREATMENT
    • ANTI COAGULATION MEASURES
      • Unfractionated heparin
      • LMW Heparin
      • Warfarin
    • Thrombolysis
    • Compression stockings
    • IVC filter
  • 34.  

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