A CASE OF DEEP VEIN THROMBOSIS FOR DISCUSSION PROF. P. VIJAYARAGHAVAN’S UNIT Dr.P.ARUL P.G.
<ul><li>45 years old Mrs. Ammakanu was admitted with chief complaints of Left leg swelling 30 days right sided abdominal p...
<ul><li>History of presenting illness: </li></ul><ul><li>Patient apparently normal before 30 days. developed left leg swel...
<ul><li>No h/o cough </li></ul><ul><li>No trauma </li></ul><ul><li>No h/o altered bladder or bowel habits. </li></ul><ul><...
<ul><li>Treatment history: </li></ul><ul><li>Patient was started on warfarin 15 days back in a private hospital. </li></ul...
<ul><li>General examination </li></ul><ul><li>Pt conscious, oriented, afebrile, </li></ul><ul><li>dyspneic, tachypneic </l...
<ul><li>Vital signs: </li></ul><ul><li>Bp 110/60mm hg  </li></ul><ul><li>Pulse 76/min </li></ul><ul><li>RR 24/min </li></u...
<ul><li>EXAMINATION OF CVS: </li></ul><ul><li>S1 S2 heard but muffled </li></ul><ul><li>RV-S3 heard  </li></ul><ul><li>EXA...
<ul><li>EXAMINATION OF THE LEFT LL: </li></ul><ul><ul><li>Limb is swollen through out, tender, dusky appearance. </li></ul...
<ul><li>INVESTIGATIONS </li></ul><ul><li>RBC 3.11million </li></ul><ul><li>WBC TC 4000 </li></ul><ul><li>DC p-77%,L-13%,E-...
<ul><li>Blood sugar-141gms/dl </li></ul><ul><li>Urea-43 </li></ul><ul><li>Creatinine-1.1 </li></ul><ul><li>LIVER FUNCTION ...
<ul><li>S.electrolytes </li></ul><ul><li>Sodium 138 </li></ul><ul><li>Potassium-4.07 </li></ul><ul><li>Chloride-102.5 </li...
<ul><li>Nitrites –negative </li></ul><ul><li>Leucocytes 8to 10 hpf </li></ul><ul><li>Epithelial cells –occasional </li></u...
 
 
 
 
<ul><li>Echo </li></ul><ul><li>Pericardial effusion+ </li></ul><ul><li>Fibrous strands+ </li></ul><ul><li>RA collapse+ </l...
<ul><li>Ultra sound abdomen </li></ul><ul><li>Minimal free fluid in morrison pouch </li></ul><ul><li>Hepatomegaly </li></u...
<ul><li>Hematologist and rheumatologist opinion </li></ul><ul><li>?APLAS </li></ul><ul><li>Vascular surgeon opinion – DVT ...
DIAGNOSIS <ul><li>A Case of DVT left lower limb probably due to  hyper coagulable state (anti phospholipid antibody syndro...
 
DIAGNOSIS – ARA CRITERIA <ul><li>Malar rash </li></ul><ul><li>Discoid rash </li></ul><ul><li>photosensitivity </li></ul><u...
 
<ul><li>DEEP VEIN THROMBOSIS </li></ul><ul><li>Commonly affects-leg veins or deep veins of pelvis. </li></ul><ul><li>Cause...
<ul><li>Surgery, hospitalisation, Immobilisation, smoking,obesity, drugs like estrogens, erythropoietin and diseases like ...
<ul><li>MECHANISM -VIRCHOWS TRIAD </li></ul><ul><li>Decreased flow rate of blood, </li></ul><ul><li>Damage of blood vessel...
<ul><li>SYMPTOMS AND SIGNS </li></ul><ul><li>No symptoms sometime </li></ul><ul><li>Pain,swelling and redness of leg </li>...
<ul><li>COMPLICATIONS </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Post phlebitic syndrome </li></ul><ul><li>INV...
<ul><li>Wells score </li></ul><ul><li>Active cancer-1point </li></ul><ul><li>Calf swelling>3cms-1pt </li></ul><ul><li>Coll...
<ul><li>Localised pain along distribution of deep venous system-1pt </li></ul><ul><li>Paralysis,paresis or recent immobili...
<ul><li>OTHER TESTS </li></ul><ul><li>CBC, pt APTT, fibrinogen, liver enzymes, renal function test and electrolytes </li><...
TREATMENT <ul><li>ANTI COAGULATION MEASURES </li></ul><ul><ul><li>Unfractionated heparin </li></ul></ul><ul><ul><li>LMW He...
 
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A Case of DVT for Discussion

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A Case of DVT for Discussion

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

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