CASE STUDY CASE STUDY : LEFT LEG CELLULITIS WITH LEFT LEG DVT

NAME: SUTHA A/P RAJAKUMAR

IC:890821-07-5454
POSITION: PEGAWAI FARMASI U41

PATIENT DEMOGRAPHICS
Name :ARB
MRN :HSNZ00203232
Age :51 Y 7 M
Sex : Male
Race :Melayu
Location :Ward 7E
Allergy: No Known Drug And Food Allergy
Admission Date/Time :02/09/2014
Discharge Date/Time: 10/09/2014 (AOR)

CHIEF COMPLAINT(S)
-left leg pain for the past 2 months

HISTORY OF PRESENT ILLNESS

- Pain of the left leg for the past 2 months with partially treated left leg cellulitis

- PAST MEDICAL HISTORY

-No known past medical history

PAST MEDICATION HISTORY

-No known past medication history

DIAGNOSIS
- Partially treated left leg cellulitis TRO left leg DVT
( Done US Doppler on 4/9/2014 DVT from left popliteal vein until left superficial femoral
vein)

Mechanism of Venous
Thromboembolism
according to Virchow
Triad

WARD MEDICATIONS

Pharmacological Discussion

Fondaparinux
Fondaparinux is a synthetic pentasaccharide sodium that selectively binds to antithrombin.
Inducing a conformational change that increases anti factor Xa without inhibiting thrombin.
Its predictable pharmacokinetic and a long elimination half life of 17 to 21 hours allows once
daily dosing.
It is eliminated unchanged in urine but its elimination is prolonged in patients aged >75 years
and in those weighing <50kg.
Fondaparinux has been shown to be effective in preventing VTE in knee and hip replacement
surgeries, hip fracture surgeries, abdominal surgeries and acute medically ill patients. It can be
used as an alternative to LMWH.
It is licensed for use outside pregnancy. The prophylactic dose is 2.5 mg given no earlier than 6
to 8 hours after surgery.

Vitamin K Antagonist
Adjusted dose warfarin, historically the primary agent used and compared with mechanical
thromboprophylaxis or placebo, was effective in reducing VTE and its consequences.
The advantages are its ease of oral administration and low cost. The disadvantages include
delayed onset on action, narrow therapeutic range, drug drug interaction and requirement for
daily monitoring of the INR . These shortcomings along with wide availability of other effective
options narrow the rationale for warfarin to be used routinely as prophylaxis.

Algorithm for initiating warfarin

Vital signs

Vital
2/9

3/9

4/9

5/9

6/9

7/9

8/9

9/9

37

37

37

37

37

36.9

36.9

signs

37
Temp

BP

120/67

122/67

122/67

123/62

120/80

127/67

120/80

120/80

RR

30

24

24

20

20

20

20

20

Laboratory Investigations

Description

4/9

5/9

6/9

7/9

8/9

9/9

WBC

19.5

14.6

15.1

18.3

14

12.1

Platelet

255

268

229

220

293

319

RBC

3.72

3.73

4.09

3.88

4.09

3.88

RENAL PROFILE

Description

Reference range

4/9

8/9

Urea

2.8-7.2

5.5

7.3

Chloride

96-108

106

102

Creatinine

45-84

74

80

Potassium

3.3-5.1

3.8

Sodium

133-145

139

137

LIVER FUNCTION TEST

DESCRIPTION

REFERENCE RANGE

8/9

A/G RATIO

NULL

ALBUMIN

35-52 g/L

50

ALP

30-120 U/L

126

ALT

< 45 U/L

17

GLOBULIN

null

34

BILIRUBIN TOTAL

5.0 21.0 umol/L

20.6

PROTEIN TOTAL

66- 83 g/L

75

CULTURE AND SENSITIVITY

3/9/14 Blood aerobe Negative
3/9/14 Body fluid Gram positive cooci nil & Gram negative bacilli nil

Drug related issues

Date

Issues

Modification/Monitoring requir
ed

Status of Intervention

Interaction
Patient was
3/9/14

To have baseline renal profile

given s/c

Done
( Urea : 5.5
Creat : 75)

Fondaparinux
7.5 mg od
HDL is 4.9

Suggested to start T.Simvastatin

mmol/L

20mg ON

Plan for statin

To check baseline for LFT

Done
(LFT normal)

To increase warfarin from 5mg od

to 6mg od for 3 days

Done

from 0.98
On tab

Counsel patient on warfarin

Done

warfarin 6mg
od

therapy regarding
dose, food interaction , administra
tion time, side effect, monitoring p
arameter

8/9/14

8/9/14

Accepted

INR 1.00
8/9/14

8/9/14