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Bilateral DVT (APS)

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by

Mohamed Elkhouly

on 25 May 2015

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Transcript of Bilateral DVT (APS)

Personal history
H.S.M, 22 years old female patient, housewife, born and living in Cairo, married for 4 years, have 3 children, youngest is 9 months old. She has no special habits of medical interest.



Complaint
Right leg swelling
Present history
The patient is coming complaining of acute onset of swelling affecting the whole right lower limb associated with redness and dull aching pain starting 3 days before admission. The swelling was not associated with fever, history of recent trauma, recent operation, prolonged immobilization or recent oral contraceptive pills use.






One month ago the patient experienced similar symptoms in her left lower limb.

She sought medical advice at that time and was diagnosed as acute deep venous thrombosis. The patient was prescribed enoxaparin twice daily for 10 days and then shifted to warfarin which was gradually increased reaching 7.5 mg per day. It was stopped two day before admission due to acute onset of menorrhagia not associated with bleeding from any other site.


The patient has no history of fever, night sweats, significant weight loss, bony pains or any body swellings apart from her lower limbs

The patient has no history of dyspnea, orthopnea, PND, cough, chest pain, palpitations or hemoptysis

There is no history of anorexia, dyspepsia, nausea, vomiting, jaundice, abdominal pain, diarrhea, constipation, tenesmus, or blood in stools.

There is no history of dysuria or change in urine color or volume.

There is no history of disturbed consciousness level, convulsions, headache, blurring of vision, weakness, intermittent claudications or any neurological manifestations.

There is no history of purpuric eruptions, ecchymotic patches or bleeding from any other sites.

Drug history
Past history
There is no history of canal water intact
There is no history of similar condition before
No history of drug allergy
No history of TB
There is no history of blood transfusion, schistosomiasis or any chronic illness

Family history
Negative consangunity
There is family history of diabetes in her mother
No history of similar condition in her family

Summary
22 years old female patient, with a history of left LL DVT on Warfarin coming complaining of:

Rt LL swelling, redness and pain
Menorrhagia

History
Examination
General
The patient is fully conscious, cooperative, well oriented to time, person and place of normal mentality and mood, lying comfortable in bed.

Weight: 95 Kg
Height: 161 cm
BMI: 36.64

Vital signs
BP:
120/50, bilateral, in both supine and sitting position

Pulse:
110/min, regular, with big pulse volume, equal on both side, no special character, arterial wall is not felt with intact peripheral pulsations

Respiratory rate:
16/min, regular

Temperature:
36.5-37 °c

Head and Neck
Pallor, no jaundice, eye redness, dryness or malar rash
No oral ulcers, erythema, patches or exudates. Tonsils are normal, no gum hypertrophy, bleeding gums, purpuric eruptions or angular stomatitis.
The trachea is central
Carotid pulsations are felt equally bilateral with no palpable thrill or audible bruit
No congested neck veins
No palpable thyroid
No palpable lymph nodes

Upper limbs
Pallor
2 scars at the flexor surface of the right arm, about 12 cm each, healed with secondary intention
No palmer erthyma, spider nevi, ecchymotic patches or purpuric eruptions
No clubbing, spooning or flattening
No flapping tremors
No scratch marks, skin rash or palpable lymph nodes
Negative pathergy test

Cardiac examination
Apex is in the 5th intercostal space in Lt MCL, localized, hyperdynamic, no palpable sounds or thrill.

Accentuated heart sounds with no murmur, gallop or rub

Chest examination
Normal shape and symmetry, no scars or dilated veins.
No tenderness, normal TVF, no palpable rhonchi or rub
Normal vesicular breathing with no adventitious sounds

Abdominal examination
Inspection:

Striae alba
No distention, moves freely with respiration
Subcostal angle is normal
No divarication of recti
Umbilicus is in its normal site, with normal colour and shape, no nodules, dilated veins or impulse on cough
Absence of scratch marks or dilated vessels

Palpation:
No tenderness or rigidity
Liver: Upper border in 5th intercostal space in Rt MCL, lower border could not be felt.
No splenomegaly

Percussion:
Resonant

Neurological examination
Free
Musculoskeletal examination
Free
Summary
22 years old female patient, with a history of left LL DVT on Warfarin coming complaining of:

Rt LL swelling, redness and pain
Menorrhagia

Pallor
Obesity
Rt LL edema, redness, hotness and tenderness. Tense calf muscles
Scattered dark colored pigmentations, las calf muscles
Accentuated heart sounds with hyperdynamic apex
Investigations
Differential:
Basophils: 0
Eosinophils: 5
Staff: 1
Segmented: 45
Lymphocytes: 34
Monocytes: 0
Reticulocytes: 1.076 %
Corrected reticylocytic count:
39,058

Conclusions:
Mild Microcytic Hypochromic Anemia
RBC’s show mild anisopoikilocytosis

LIVER:
Average size with homogenous texture and uniform echopattern. No focal areas or dilated intrahepatic biliary radicals. Portal vein is not dilated.
SPLEEN: Average size (115 mm) of homogenous texture. Splenic vein is not dilated.

GALLBLADDER:
Average in size, no calculi or mud are seen in supine or right lateral position. Common bile duct is not dilated

PANCREAS:
Normal size and pattern

KIDNEYS:
Both are of normal size , shape and position with smooth outlines. Normal parenchymal thickness and echogenicity. There is no cysts, calculi or back pressure changes

SUPRARENAL:
Free

AORTA: No enlarged para aortic lymph nodes

ASCITES:
No ascites

The patient received:

2 units of PRBC’s
Folic acid 1x3
Acetamenophen PRN

The follow up investigations
were as following:

Differential:
Basophils: 0
Eosinophils: 2
Staff: 2
Segmented: 58
Lymphocytes: 32
Monocytes: 6
Reticulocytes:
6.3 %
Corrected reticylocytic count: 205,380

Conclusions:
Mild Normocytic Normochromic Anemia
RBC’s show mild anisocytosis

ECG
Bilateral LL venous duplex
Deep system:
The left SFV, POP vein and PTV as well as deep calf veins are totally occluded, distended, filled with hypoechoic heterogenous thrombotic material, with no detectable flow inside by color or doppler analysis
The EIV and CFV is patetnt compressible showing normal color flow inside

Superficial system:
Patent, totally compressible and competent saphenous veins and junctions

Conclusion:
Acute extensive femoropopliteal DVT of the left lower limb

Bilateral LL venous duplex
Deep system:
Bilateral distal segment, dilated SFV containing well adherent, echogenic thrombus with no free floating tail extending distally to proximal part of posterior tibial vein
Free EIV, CFV and IVC

Superficial system:
Patent, totally compressible and competent saphenous veins and junctions

Conclusion:
Bilateral subacute femoropopliteal DVT
Echocardiography
Normal left ventricular systolic function and dimensions, EF 60 %
Normal cardiac valves and other cardiac structures
Normal left atrium
Normal right sided chambers
No intracardiac masses or thrombi
No pericardial effusion

Chest X-ray
Imaging
She has no history of hair loss, photosensitivity, malar rash, raynaud’s, joint pain or swelling, myalgia, oral or genital ulcers.

The patient is not known to diabetic or hypertensive.



Lower limbs
Rt LL:
Extensive edema affecting the whole LL. Redness, hotness and tenderness.
Tense and tender calf muscle
Peripheral pulsations are felt
No palpable lymph nodes

Lt LL:
Scattered dark colored pigmentations
lax calf muscles
Peripheral pulsations are felt

Laboratory
Enosaparin 60 units/12 hours
Warfarin 7.5 mg once/ day

Abdominal ultrasonography
Menstrual history
The patient menarche was at the age of 12. Her menses are regular, every 28 days, lasting 4 days of average amount.

The patient has a history of oral contraceptive pills intake following her last pregnancy stopped after one month due to menorrhagia

Obstetric history
The patient is G3P3L3.
Normal uncomplicated vaginal deliveries, yielding 3 viable children
There is no history of abortions or premature labors
The patient was advised to stop lactation one month ago when she was prescribed warfarin.

Ophthalmological examination
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