Major Case Presentation on Acute Pulmonary Embolism with DVT
A 46-year-old female admitted with acute pulmonary embolism and DVT. Chief complaints of chest pain, history of back surgery. Laboratory investigations reveal elevated RBC and WBC levels. Prothrombin time and D-Dimer test results indicate clot formation. SOAP note highlights subjective and objective findings. Diagnosis of acute pulmonary embolism with DVT made. Assessment lists chest pain, acute pulmonary embolism, and DVT. Learn about the causes and implications of these conditions in detail.
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Presentation Transcript
Major case presentation on Acute Pulmonary Embolism with Deep Vein Thrombosis By
SCENARIO: Here is a 46 years old female patient admitted in surgery department and diagnosed as Acute pulmonary embolism with DVT and hospitalized for 7 days. CHIEF COMPLAINTS: c/o chest pain since 3days. HISTORY OF PRESENT ILLNESS: Patient was apparently alright 3days back when she developed chest pain which occurred on exertion and was not relieved even while taking rest. PAST MEDICAL HISTORY: H/o surgery over the back 2 months ago(lumbar disectomy). PAST MEDICATION HISTORY: Nothing significant.
LABORATORY INVESTIGATIONS: CBC CBC RBC Patient Patient value 5.20 value Normal value Normal value 3.8-4.8 millions/ l WBC 12290 4000- 11000cumm M: < 10, F: < 20 80-100 fl 27-32 g/dl ESR (mm/hr) MCV MCH 90 77.1 24.6 URINE EXAMINATION: Albumin is present in traces.
Prothrombin time (PT, INR) Patient value Patient value 17.5 17.5 10 10- -14 range range -----do--- 14sec normal sec normal Control value 13.9 INR 1.30 -----do--- D-DIMER TEST 2588.46 ng/ml normal range - < 500 ng/ml Echo Moderate pulmonary hypertension RA/RV mildly dilated RV free wall hypokinesia Troponin T: negative
SOAP NOTE: Subjective: Here is a 46yrs old female presenting with complaints of chest pain since 3 days. Objective: RBC was increased to 5.20 millions/ l due decreased oxygen levels. WBC increased to 12290 cumm that implies presence of infarction. ESR increased to 90 that is due to infection. MCV and MCH levels are decreased to 77.1 and 24.6 respectively that implies hypochromia. Albumin present in traces that implies there may be risk of glomerulonephritis.
As the INR value is 1.30 that indicates there is a clot Elevated D-Dimer indicates continuous fibrinolytic process DVT, pulmonary embolism and Disseminated intravascular coagulation (DIC). Diagnosis: By observing the above subjective and objective data the patient was diagnosed with Acute pulmonary embolism with DVT ASSESSMENT: Problem list: 1.Chest pain 2.Acute pulmonary embolism 3.DVT
Chest pain: it occurs due to ischemia and decreased oxygen supply the myocardium function declines and necrosis occurs leading to chest pain Acute pulmonary embolism: A pulmonary embolism is a thrombus that arises from the systemic circulation and lodges in the pulmonary artery or one of its branches, causing complete or pulmonary obstruction of pulmonary flow. DVT: A deep vein thrombosis is a thrombus composed of cellular material (red and white blood cells and platelets) bound together with fibrin strands.
PLAN OF CARE: GOALS OF THERAPY: To prevent the development of pulmonary embolism and the post thrombotic syndrome To reduce morbidity and mortality from the acute event To minimize the adverse effects and the cost of treatment
S.N o Brand Name Generic Name Dose Day 1 2 3 4 5 6 7 1. Inj. Lomoh s/c Enoxaparin 0.6ml 1-0-1 Y Y Y Y Y Y Y 2. Tab.Clopitab A Clopidogrel 150mg 0-1-0 Y Y Aspirin 3. Tab. Atorsave Atorvastatin 20mg 0-0-1 Y Y 4. Tab. Isonorm SR Isosorbide mono nitrate 30mg 1-0-0 Y 5. Tab. Nicostar Nicorandil 5mg 1-0-1 Y Y 6. Tab. Metpure XL Metoprolol 25mg 1-0-0 Y Y 7. Inj. Pantodac Pantoprazole IV stat Y Y Y 8. Tab. Zolfresh Zolpidem 5mg 0-0-1 Y Y 9. Tab. Warf Warfarin 0-0-1 Y Y Y Y Y Y Y 10. Inj. Amoxicillin+ 1.2gm Y Y
11. Tab. Dolo Paracetamol 650mg Y Y Y Y Y Sos 12. Inj. STK 1amp in 5ml Bolus 30ml 2ml/hr Y 13. Syp. Neogadine elixir Neogadine 2tsp 1-1-1 Y Y Y Y Y 14. Cap. Recovit total Glutamic acid 0-1-0 Y Y 15. Inj Tramadol In 100ml NS 1-0-1 Y 16. T. Calcimox Calcium corbonate 500mg 0-1-0 Y 17. T. Ultra D3 Vit D, Cholecalcifer ol 0-1-0 Y Y 18. Inj. Emset IV ondansetron 4mg Y Y 1-1-1 19. Inj. Pan IV Pantoprazol e 40mg 1-0-0 Y Y 20. Tab. Zerodol MR Aceclofenac 1-0-1 Y Y
Drug-drug interactions: Warfarin + Tramadol Increases risk of bleeding Warfarin + Amoxicillin Increases risk of bleeding. ADR s: Nausea caused due to aceclofenac and tramodol Management ondansetron , Domperidon are prescribed. For VTE heparin and warfarin therapy overlapped for atleast 4-5 days. The UFH/LMWH can then be discontinued once the INR is within the desired range for 2 consecutive days. In older patients (>65yrs) starting dose 2.5mg
INR target for warfarin therapy 2 to 3 for DVT or PE If 5mg warfarin was given then INR on day 5 is less than 1.5 increase the dose 10% - 25% LMWH should be stopped on 5thday and then LMWH discontinued for 2 days and INR should be done. INR and PT was not done on 5thday Discharge drugs: Inj. Lomo H Tab. Warf 5mg Syp. Neogadine Tab. Dolo 650mg , 0.6ml 1-0-1
