CASE FORMULATION

Formulate a case based on:

A G2P2(2002) POSTPARTUM CLIENT, EXPERIENCING CALF PAIN, S/P LOW-TRANSVERSE CESAREAN SECTION. UPON ASSESSMENT, CLIENT COMPLAINED OF 7/10 SHARP PAIN
IN HER INCISION AND AVOIDS AMBULATING

BIOGRAPHICAL DATA
● Clients Name: Client R.R.R.
● Age: 33 Years old
● Gender: Female
● Weight: 174 lbs
● Height: 5’4 ft
● Date of birth: February 11, 1988
● Address: 1234 Village Pardo, Cebu City
● Religion: Roman Catholic
● Occupation: Client R.R.R. Is a full time lawyer for 4 years and her husband is a house husband, who takes care of their 2 children at home.
● Marital status: Client R.R.R . is married for 7 years and got married at the age of 22 years old.
● Highest Educational Attainment: College graduate

LEARNER’S PROFILE

Client R.R.R. is a college graduate and loves her job, she likes everything organized, neat and runs the way she likes or plans. She understands and speaks 5 different languages:
English, Tagalog, Cebuano, Dutch, and Latin. The client excelled in all her academic records during her high school and college years, she was always eager to learn new knowledge in all
subjects and lessons, especially when it is related to economics and justice. The client is a visual, verbal and logical learner, according to the client, she prefers learning through observing
things and visualizing information, she also prefers using words both in speech and writing when it comes to learning, and lastly she prefers learning through solving complex problems by
employing strategies.

MEDICAL HISTORY

Client R.R.R. was previously hospitalized in CVGH due to labor via NSVD section last 3/9/2019.She was 30 years old that time and the patient could not recall her previous medications.
During her previous pregnancy, she was in labor for 20 hours and diagnosed with thrombophlebitis and was managed by taking nonsteroidal anti-inflammatory especifically Ibuprofen (Advil) as
prescribed by her doctor. Client is currently postpartum.

Clients had received complete childhood and adult immunization in a private hospital. She has no known allergies to latex, contrast dyes, pollen, seafoods, and medications/anesthesia.
She also had no previous blood transfusion. Moreover, she is non-hypertensive and non-asthamtic.

Client’s childhood illnesses include mumps, chicken pox, and measles.

The client’s health practices include eating healthy but she does not exercise because she believes eating healthy is enough. Moreover, the client is diabetic.

Client’s LMP was on June 2, 2020

STORYLINE

Client R.R.R. is a 33 years old postpartum client. One day after her labor via Cesarean section, client reported that she did not try to ambulate herself and just layed on her bed after
being transferred to her private room because of experiencing a sudden, excruciating, sharp, constant pain on the incision site. In the evening of the very same day, she experienced a
throbbing pain in her left calf and tried to alleviate the pain by elevating her feet and placing it above a pillow. She tried doing this for the whole night however it did not change anything. The
following day, she complained that there was a slight swelling on the affected leg and observed that the back of her left calf, particularly below the knee had turned red and warm upon touch
and the pain worsened, refusing to ambulate herself. The pain on her incision site still did not subside and rated the pain 7/10.

EXAMINATION

Upon assessment, the blood pressure is 105/58 mmHg. Left lower leg appears to be red, swollen and shiny. There is evident hard inflamed vessel in the affected leg.

DIAGNOSIS AND MANAGEMENT

Diagnostic/ laboratory tests:

D-Dimer blood test (Figure 1.0)

Actual Finding Normal Finding

284 ng/mL D-DU < 250 ng/mL D-DU

Hematology: Complete Blood Count (Figure 2.0)

Component Results Normal Values

WBC 10.9 4.10-10.9 k/uL

NEU 7.2 2.5-7.5 47%-80%

LYM 2.02 1.0-4.0 13%-40%

MONO .804 0.1-1.2 2%-11%

EOS .089 0-0.5 0%-2%

BASO .068 0-0.1 0%-2%

RBC 3.34 k/uL 4.0-5.2 k/ uL

HGB 9.64 g/dL 12-16 g/dL

HCT 30.6% 36%-46%

MCV 82.4 80-100fL

MCH 28.6 26-34 pg

MCHC 32.4 g/dL 31-36 g/dL

RDW 11.84% 11.6%-18%

PLT 120 140-440

MPV 26.57 fL 0.99.9 fL

Duplex and Doppler ultrasonography; Lower-extremity venous duplex ultrasound with B-mode compression maneuver and Doppler Evaluation (D) (Figure 3.0)

Duplex with B-mode compression maneuver

 Doppler Ultrasound

Figure 3.0
Investigation

Ultrasonography A -B-mode image of a dilated iliac vein next to the external iliac artery

Ultrasonography B -Loss of compressibility of the external iliac vein

Ultrasonography C -Spectral Doppler Waveform analysis with absent of venous flow in the thrombose and occluded external
iliac vein

Ultrasonography D & E -Color-flow Doppler image: absent flow in common and femoral vein
MANAGEMENT:

Day of Hospitalization Medical/Surgical/ Treatment done

1 (admission) ➢ Performed low-transverse Cesarean section

2 ➢ Performed health history and physical assessment

➢ Performed BUBBLESHE Assessment
➢ Taught patient in choosing a breastfeeding position that puts less pressure on her incision
➢ Encouraged patient to ambulate

3 ➢ Conducted dorsiflexion sign test

➢ Administered Fondaparinux (Arixtra) 7.5 mg subcutaneously qd
➢ Administered Ibuprofen (Advil) 800 mg PO q6H PC
➢ Provided a heating pad and an abdominal binder (compression belt)
➢ Encouraged patient to ambulate

4 ➢ Administered Fondaparinux (Arixtra) 7.5 mg subcutaneously qd

➢ Administered Ibuprofen (Advil) 800 mg PO q6H PC
➢ Monitored patient’s ambulation and management of pain

References:
Flagg, J.S. & Pillitteri, A. (2018). A Woman with Venous Thromboembolic Disease. Maternal and Child Health Nursing (Care of the Childrearing Family) Eighth Edition, 498, 659.
Gillespie, C. & Nwadike, V. R. (2019). What You Should Know About Deep Vein Thrombosis (DVT) in Pregnancy. Healthline. Retrieved from:
https://www.healthline.com/health/dvt-in-pregnancy#symptoms
Patel,K. MD. (2019). Deep Venous Thrombosis (DVT). Retrieved from Deep Venous Thrombosis (DVT): Practice Essentials, Background, Anatomy (medscape.com)
FAQ519 (2020). Postpartum Pain Management. Retrieved from Postpartum Pain Management | ACOG
Medscape (2021).ibuprofen (Rx, OTC). Retrieved from Advil, Motrin (ibuprofen) dosing, indications, interactions, adverse effects, and more (medscape.com)