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Case Report - Deep Vein Thrombosis

This document summarizes a 55-year-old female patient's medical record and hospital admission. She presented with swelling in both legs that had been worsening over the past two weeks. Examination found pitting edema and pain in both legs. Tests showed elevated D-dimer and low albumin levels. She was diagnosed with deep vein thrombosis and hypoalbuminemia. Her treatment plan included bed rest, leg elevation, compression stockings, heparin infusion, and medications to address symptoms and increase albumin levels. Further tests such as Doppler ultrasound and echocardiogram were also recommended.

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Andi Meidin Anugerah
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307 views12 pages

Case Report - Deep Vein Thrombosis

This document summarizes a 55-year-old female patient's medical record and hospital admission. She presented with swelling in both legs that had been worsening over the past two weeks. Examination found pitting edema and pain in both legs. Tests showed elevated D-dimer and low albumin levels. She was diagnosed with deep vein thrombosis and hypoalbuminemia. Her treatment plan included bed rest, leg elevation, compression stockings, heparin infusion, and medications to address symptoms and increase albumin levels. Further tests such as Doppler ultrasound and echocardiogram were also recommended.

Uploaded by

Andi Meidin Anugerah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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 Name : Mrs.

SR

 Date of Birth : 31-12-1962 (55 y.o)

 Address : Majene, West Sulawesi

 Medical Record : 851515

 Date of Admission : 4 August 2018


 Chief Complaint: Swelling in both legs

 Swelling in right leg were felt 2 weeks before admitted to the hospital,
and worsening since last 5 days and affected the left leg too. Swelling
initially develops from foots, then spreads to the calves and thighs. The
right leg is more swollen than the left leg. Both legs felt pain, and the
patient has difficulty to move his legs due to pain.
 There are no shortness of breath, no cough, no chest pain. Fever was
present 2 days before admitted to the hospital. Nausea and vomit are
present. Normal urination and defecation.
 There were no history of trauma, hypertension, or DM. There were history
of bedrest for the last 1.5 months with chronic gastritis and hepatitis.
 BP: 100/70 mmHg, HR : 109x/m regular, RR : 20 x/m, T: 37,0°C, O2
saturation 99%
 Conjunctiva not anemic, sclera not icteric
 JVP R+2 cmH2O
 Lung :Vesicular breath sound, no ronchi and no wheezing
 Cor : Heart size in normal limit. Heart sound S1/ S2 regular, murmur (-)
 Abdomen : Normal Peristaltic, hepar and lien aren’t palpable
 Extremity:
Edema dorsalis pedis et pretibial sinistra et dextra, Pitting edema (+),
redness (+), tenderness (+), pain (+), warm.
Posterior tibial artery pulses (+).
EXAMINATION RESULT REFERRENCE UNIT

WBC 8,27 4,00-10,00 103/ul

RBC 5,24 4,00-6,00 106/ul

PLT 282 150-400 103/ul

HGB 12,6 12,0-16,0 gr/dl

PT 12,3 10-14 Detik

APTT 35,4 22,0-30,0 Detik

INR 1,18 -

GDS 112 140 Mg/dl

Ureum 23 10-50 Mg/dl

Kreatinin 0,76 P (<1,1) Mg/dl

SGOT 15 < 38 U/L

SGPT 20 < 41 U/L

Albumin 2,5 3,5-5,0 Gr/dl

D-Dimer > 5,0 < 0,5 ug/ml

Natrium 135 136-145 Mmol/l


Sinus Rhythm, HR 101 bpm, Normoaxis, P wave 0,12 s, QRS 0,08s,

Conclusion: Sinus Tachycardia


 Deep Vein Thrombosis

 Hipoalbuminemia
1. Non-Pharmacology
 Bedrest, Leg raise
 Stocking Compression

2. Pharmacology
 Unfractioned Heparin (UFH) bolus i.v. 5000  Domperidone 10 mg/8h/oral
U, continue by 1500 U/hour/infuse pump
 Furosemide 40 mg/12h/intravena
(aPTT check)
 Human albumin 25% 100 ml/24h/intravena
 Simarc (warfarin) 2 mg/24h/oral

 Ardium 100 mg/8h/oral

 Lansoprazole 30 mg/12h/intravena
 Doppler Ultrasonography

 Chest X-Ray

 Echocardiography

 Thrombolitic

 Check : aPTT/6 hour, albumin

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