Major case presentation on Acute Pulmonary Embolism with - PowerPoint Presentation

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Major case presentation on Acute Pulmonary Embolism with Deep Vein Thrombosis

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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:

URINE EXAMINATION:

Albumin is present in traces.

CBC

Patient

value

Normal value

RBC

5.20

3.8-4.8 millions/

µl

WBC

12290

4000-11000cumm

ESR (mm/hr)

90

M: < 10,

F: < 20

MCV

77.1

80-100 fl

MCH

24.6

27-32 g/dl

Prothrombin time (PT, INR)

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

Patient value

17.5

10-14

sec normal range

Control value

13.9

-----do---

INR

1.30

-----do---

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/µl 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 pain2.Acute pulmonary embolism3.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 inthe 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 eventTo minimize the adverse effects and the cost of treatment

S.No

Brand Name

Generic Name

DoseDay12345671.

Inj.

Lomoh s/cEnoxaparin0.6ml1-0-1YYYYYYY2. Tab.Clopitab AClopidogrelAspirin150mg

0-1-0

Y

Y

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.

Agumentin

Amoxicillin+

claculanate

1.2gm

1-1-1

Y

Y

11.

Tab.

Dolo

Paracetamol650mgSosYYYYY12.Inj. STK 1amp in 5ml

Bolus 30ml

2ml/hrY13.Syp. Neogadine elixirNeogadine2tsp1-1-1YYY

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,

Cholecalciferol

0-1-0

Y

Y

18.

Inj.

Emset

IV

ondansetron

4mg

1-1-1

Y

Y

19.

Inj. Pan IV

Pantoprazole

40mg

1-0-0

Y

Y

20.

Tab.

Zerodol

MR

Aceclofenac

1-0-1

Y

Y

21.

Cap.

Cyra

D

Domperidon

Rabeprazole

1-0-0

Y

22.

Cap.

Lycoprez

M

0-1-0

Y

Drug-drug interactions:

Warfarin +

Tramadol

– Increases risk of bleedingWarfarin + 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 5

th day and then LMWH discontinued for 2 days and INR should be done.INR and PT was not done on 5th day Discharge drugs:

Inj.

Lomo H , 0.6ml 1-0-1Tab. Warf 5mgSyp. Neogadine Tab. Dolo 650mg

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