1. Major case presentation on Acute Pulmonary Embolism with Deep Vein ThrombosisBy

2. 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.

3. LABORATORY INVESTIGATIONS:
URINE EXAMINATION:
Albumin is present in traces.
CBC
Patient value
Normal value
RBC
5.20
millions/µl
WBC
12290
cumm
ESR (mm/hr) 90
M: < 10, F: < 20
MCV
77.1 fl
MCH
24.6
27-32 g/dl

4. Patient value 17.5 10-14 sec normal range Control value 13.9
Prothrombin time (PT, INR)
D-DIMER TEST – 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

5. 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 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.

6. 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

7. 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.

8. 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

9. S.No
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 2.
Tab.Clopitab A
Clopidogrel
Aspirin
150mg
0-1-0 3.
Tab. Atorsave
Atorvastatin
20mg
0-0-1 4.
Tab. Isonorm SR
Isosorbide mono nitrate
30mg
1-0-0 5.
Tab. Nicostar
Nicorandil
5mg 6.
Tab. Metpure XL
Metoprolol
25mg 7.
Inj. Pantodac
Pantoprazole
IV stat 8.
Tab. Zolfresh
Zolpidem 9.
Tab. Warf
Warfarin
10.
Inj. Agumentin
Amoxicillin+ claculanate
1.2gm
1-1-1

10. 11.
Tab. Dolo
Paracetamol
650mg
Sos Y
12.
Inj. STK 1amp in 5ml
Bolus 30ml
2ml/hr
13.
Syp. Neogadine elixir
Neogadine
2tsp
1-1-1
14.
Cap. Recovit total
Glutamic acid
0-1-0
15.
Inj Tramadol
In 100ml NS
1-0-1
16.
T. Calcimox
Calcium corbonate
500mg
17.
T. Ultra D3
Vit D, Cholecalciferol
18.
Inj. Emset IV
ondansetron
4mg
19.
Inj. Pan IV
Pantoprazole
40mg
1-0-0
20.
Tab. Zerodol MR
Aceclofenac
21.
Cap. Cyra D
Domperidon
Rabeprazole
22.
Cap. Lycoprez M

11. 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

12. 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 5th 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 1-0-1
Tab. Warf 5mg
Syp. Neogadine
Tab. Dolo 650mg

13. THANKYOU