A 70-year-old male smoker presented with fever, swelling and pain in his left hand for 2 weeks. He was diagnosed with diabetes 2 years ago. Doppler ultrasound revealed a deep vein thrombosis in the left upper limb. He was started on enoxaparin injections, aceclofenac tablets, paracetamol, acenocoumarol and tramadol as needed for pain. His symptoms improved over the next few days with treatment and regular monitoring. Lifestyle changes like regular exercise and compression stockings can help prevent future blood clots.

1. Presented by:
G.Sravani

2. Name : XXXX
Age: 70years
Sex: Male
Ward : Male medical ward
Consultant doctor: Dr. kantha Reddy MBBS
Chief complaints :fever ,Swelling and pain in left hand since 2 weeks
Past medical history :Diabetic since 2 years using medications glimepride 1mg
and metformin 250mg
Weight : 80kg
Diet : Mixed
Sleep : Normal
Appetite : Normal
Alcoholic or smoker : Smoker
Bowel and bladder habits : Normal

3. Vitals
Temp: 97.8F
BP: 110/70 mm of Hg
RR: 22Cpm
PR: 80bpm
Activated partial thromboplastin time- 21 sec (21-30 sec)
Prothrombin time :
Test : 18.0 sec(11-18)
Control : 13.2 sec
INR: 1.33 (0.8-1.2)
Doppler study of left upper limb venous system :
•Dilated subclavian , axillary and proximal brochial vein seen filled with
hypoechoic thrombus causing complete occlusion
•Subcutaneous edema in left arm and forearm

4. Based on the subjective and objective evidence the
patient was known case of diabetes and newly
diagnosed with Deep Vein Thrombosis .

5. Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein,
most commonly in the legs or in the arms.

6. •The coagulation cascade is a stepwise series of enzymatic reactions that result in
formation of fibrin mesh.
•It can be triggered either by intrinsic or extrinsic
pathway
•Intrinsic pathway is activated when negatively
charged surface in contact with the blood activate
factor XII and activated platelets convert factor XI .
•the extrinsic pathway is activated when damaged
vascular tissue release tissue thromboplastin.
•Vascular injury also exposes the subendothelium
causing adherence, activation, and aggregation of
platelets.
•The intrensic and extrensic pathway meet at a
common point with the activation of factor X.
with its partner, factor Va ,Xa converts prothrombin to
thrombin, which then cleaves fibrinogen to fibrin.
•Factor XIII covalently bonds fibrin stands together

7. People with an upper extremity DVT, or a blood clot in the arm, may not experience
symptoms. If they do, symptoms include:
•Neck pain
•Shoulder pain
•Swelling in the arm or hand
•Blue- or darker-tinted skin color
•Pain that moves from the arm to the forearm
•Weakness in the hand
Common symptoms:
• Swelling in extremities
•Tenderness
• Warm skin
•Red or discolored skin

8.  Injury: Damage to a blood vessel’s wall can narrow or block blood flow. A
blood clot may form as a result.
Trauma or bone fracture
Surgery: Blood vessels can be damaged during surgery, which can lead to the
development of a blood clot. Bed rest with little to no movement after surgery
may also increase your risk of developing a blood clot.
particularly surgery of the hip or leg, or abdominal surgery
Reduced mobility or inactivity: When you sit frequently, blood can collect
in your legs, especially the lower parts. If you’re unable to move for extended
periods of time, the blood flow in your legs can slow down. This can cause a
clot to develop.
Certain medications. Some medications increase the chances your blood will
form a clot
Pregnancy
Birth control pills or hormones taken for symptoms of menopause
Varicose veins

10. Age. Being older than 60 increases your risk
of DVT, though it can occur at any age.
Sitting for long periods of time, such as when
driving or flying. When your legs remain still for
hours, your calf muscles don't contract. Muscle
contractions normally help blood circulate.
Prolonged bed rest, such as during a long
hospital stay, or paralysis. Blood clots can form
in the calves of your legs if your calf muscles
don't move for long periods.
Injury or surgery. Injury to your veins or
surgery can increase the risk of blood clots.
Pregnancy. increases the pressure in the veins
in your pelvis and legs. Women with an inherited
clotting disorder are especially at risk. The risk of
blood clots from pregnancy can continue for up to
six weeks after you have your baby.

11. Being overweight or obese. Being overweight increases the pressure in the veins
in your pelvis and legs.
Smoking. Smoking affects blood clotting and circulation, which can increase your
risk of DVT.
Cancer. Some forms of cancer increase substances in your blood that cause your
blood to clot. Some forms of cancer treatment also increase the risk of blood clots.
Heart failure. This increases your risk of DVT and pulmonary embolism. Because
people with heart failure have limited heart and lung function, the symptoms caused
by even a small pulmonary embolism are more noticeable.
Inflammatory bowel disease. Bowel diseases, such as ulcerative colitis increase
the risk of DVT.
A personal or family history of DVT or PE. If you or someone in your family
has had one or both of these, you might be at greater risk of developing DVT.
Genetics. Some people inherit genetic risk factors or disorders, such as factor V
Leiden, that make their blood clot more easily. An inherited disorder on its own
might not cause blood clots unless combined with one or more other risk factors.
Birth control pills (oral contraceptives) or hormone replacement therapy. Both
can increase your blood's ability to clot.

12. •Thrombolytic agents - Alteplase -100mg IV over 2hrs
Reteplase -10 units IV bolus
Streptokinase-250000 units IV over 30 min
Urokinase -4400 IU/KG IV over 10 min
•Anticoagulant - Warfarin
Heparin 17-20 units /kg/hr
Enoxaparin -20-40 mg s/c
•Anti-platelets- Aspirin
Clopidogrel75mg
•Direct thrombin inhibitors –Lepirudin 0.5µg/kg
Bivalirudin
•Factor Xa inhibitors- Fondaparinux 2.5- 10 mg

13. Pulmonary embolism (PE). PE is a potentially life-threatening complication
associated with DVT. It occurs when a blood vessel in your lung becomes
blocked by a blood clot (thrombus) that travels to your lung from another part of
your body, usually your leg.
It's important to get immediate medical help if you have signs and symptoms
of PE. Sudden shortness of breath, chest pain while inhaling or coughing, rapid
breathing, rapid pulse, feeling faint or fainting, and coughing up blood may
occur with a PE.
Postphlebitic syndrome. Damage to your veins from the blood clot reduces
blood flow in the affected areas, causing leg pain and swelling, skin
discoloration and skin sores.
Treatment complications. Complications may result from blood thinners used
to treat DVTs. Bleeding (hemorrhage) is a worrisome side effect of blood
thinners. It's important to have regular blood tests while taking such medications.

14. Prognosis Treatment
DAY-1
Temp -97.8F
BP-130/90 mm of Hg
RR-22Cpm
PR-84bpm
APTT-21sec
PROTHROMBIN TIME:
Test-18 sec
control -13.2 sec
INR-1.33
DOPPLER STUDY OF LEFT UPPER LIMB
VENOUS SYSTEM:
•Dilated subclavian , axillary and proximal
brochial vein seen filled with hypoechoic
thrombus causing complete occlusion
•Subcutaneous edema in left arm and forearm
Rx
1.Inj. Enoxaparin 60mg SC –BD
2.Tab. Aceclofenac -100mg PO-
BD
3.Tab.paracetamol 650mgPO-TID
4.Tab.acenocoumarol 4mg PO-OD
5.Tab.tramadol 50mg IV-SOS

15. Prognosis Treatment
Day 2:
Temp :98.4F
BP:120/70 mm of Hg
PR:86 bpm
RR: 22Cpm
C.S.T
Day 3:
Temp : 97.8F
PR: 82bpm
C.S.T

16. S.NO Brand name Generic name Indication dose Route freq
1 Inj. Cutenox Enoxaparin Anticoagulant 60mg SC BD
2 Tab.Aceclofenac Aceclofenac Analgesic 100mg PO BD
3 Tab. pct paracetamol Analgesic and
antipyretic
650mg PO TID
4 Tab. Aceno Acenocoumarol Anticoagulant 4mg PO OD
5 Tab .Tramadol Tramadol analgesic 50mg IV SOS

17. Drug Mechanism ADR MP
Enoxaparin Enoxaparin binds to antithrombin III, a serine
protease inhibitor, forming a complex that
irreversibly inactivates factor Xa, which is
frequently used to monitor anticoagulation in the
clinical setting
Thrombocytope
nia
Hemorrhage
Anemia
Prothrombin time
CBC,BT,CT
Platelet count
Anti-Factor Xa
levels
Aceclofenac aceclofenac is a prostaglandin synthetase
(cyclooxygenase) inhibitor, which decreases
prostaglandin and leukotriene production,
therefore inhibiting the inflammatory process
Renal toxicity,
hepato toxicity
Serum Na,
potassium, blood
urea nitrogen, and
creatinine,SGPT
Paracetamol it inhibits cyclooxygenase enzymes particularly
COX-3 in the CNS. In the peripheral tissues, it
stimulates the activity of descending
serotonergic pathways that blocks the
transmission of signals to spinal cord from the
peripheral tissues. The antipyretic action is
related to the inhibition of the synthesis of PGE1
in the hypothalamus
Liver failure,
Constipation ,
Nausea,
Vomiting,
Agitation
LFT,
Electrolytes

18. Drug MOA ADR MP
Acenocoumarol it is a coumarin derivative, with
anticoagulant effects mediated via
inhibition of vitamin.K epoxide reductase,
which impairs gamma carboxylation of
glutamic acid residues of the precursor
proteins of factors II, VII, IX, and X
Hemorrhage Coagulation
tests ,
prothrombin time.
Tramadol TraMADol is a centrally-acting synthetic
opioid analgesic that exerts its effect
through the binding of parent drug and O-
desmethyl-traMADol (M1) metabolite to
mu-opioid receptors and through the weak
inhibition of norepinephrine and serotonin
reuptake
Vomiting,
Nausea,
Hypoglycemia,
Allergic reaction
Hypoglycemia,
Pain reduction,
Hypotension

19. Drug drug interactions :
1.Acenocoumarol + aceclofen -Concurrent use of ANTICOAGULANTS and
NSAIDS may result in increased risk of bleeding.
Clinical management - If used concomitantly, monitor for signs of bleeding
2.Aceclofen + enaxoparin - Concurrent use of low-molecular-weight heparins
and nsaids may result in an increased risk of bleeding.
Clinical management- if concomitant use required, use extreme caution and
closely monitor the patient for signs and symptoms of bleeding
3.Acenocoumarol + enoxaparin -Concurrent use of acenocoumarol and
enoxaparin may result in increased risk of bleeding.
Clinical management- losely monitor the patient for signs and symptoms of
bleeding, and neurological impairment in patients who are receiving neuraxial
anesthesia or undergoing spinal puncture
Rationalitay : the given treatment is rational

20. •Do regular walking.
•Limiting the amount of time you spend sitting
•Exercising daily, mainly walking, swimming, or other activities that promote good
blood circulation
•Avoid wearing tight-fitting clothes for extended periods
•Drinking lots of fluids
•Consuming foods that act as natural blood thinners to reduce the risk of developing
blood clots, such as vitamin E, ginger, cayenne pepper, garlic, turmeric, and cinnamon
•Wear graduated compression stockings: These specially fitted stockings are tight at the
feet and become gradually looser up on the leg, creating gentle pressure that keeps
blood from pooling and clotting.
•Elevate the affected leg: Make sure your foot is higher than your hip.
•Lower your blood pressure with dietary changes, like reducing your salt and sugar
intake.
•Lose weight if you’re overweight.