CASE BASED

DISCUSSION

MOHANA PREESHA
121303556
SUMMARY
Mr.Zulkarnain bin Othman, 32 year old Malay male who works as a policeman
presented to the ED on 9/1/18 with complaints of fever for 2 weeks, cough for 2
weeks and left sided calf pain for 1 week.

Patient was apparently well until 2 weeks ago. Fever started on 26/12/2017, on
and off with chills and rigor. It relieves temporarily on T.PCM. There is no
documented temperature at home. No evening rise of temperature and no night
sweats.

The cough also started 2 weeks ago with production of whitish sputum. Patient
claimed that there would be streaks of blood on sputum on and off. It was
associated with SOB, orthopnea and PND.
Left calf pain for 1 week, associated with leg calf swelling. There is pain during
walking and the pain is progressively worsening. Pain score of 6/10 on walking.
No radiation of pain.

Patient visited GP (27/12) and was treated of CAP, given antibiotics but symptoms
was not resolved. T.Augmentin 625mg BD and T.Azithromycin 500mg OD. Patient
went to Hospital jasin on 28/12, CXR done and showed right lower zone
consolidation and was diagnosed as pneumonia and the antibiotics were changed
to T.EES 800mg BD.
Symptoms still did not resolve and patient presented again on 9/1/18 with left calf
swelling which he noted since 2/11/18. It is a/w left calf pain and limping.

No chest pain, palpitation, no GIT symptoms, no unilateral weakness, no

headache and no blurring of vision, no family history of DVT/PE/lung disease, no
recent surgery/immobilization/travelling in long distance/trauma

*Active smoker-20sticks/day - pack years : 17 pack years

ON EXAMINATION
Patient is alert, conscious and appears to be tachypneic. He is warm to touch,
CRT<2s. BMI of patient is 24.8kg/m2.

Vitals : PR : 132bpm, regular rhythm, normal volume and character

RR : 28 breaths/min

BP : 114/71 mmHg

SpO2 : 98% under NPO2 3L/min & 93% under room air

Temperature : 38.2
 ● Left calf swelling and redness, warm to touch, tender, tense and firm
● Homan’s sign : positive
● DPA/PTA palpable
● Right leg popliteal vein is palpable whereas left leg popliteal vein is unable to
appreciate due to pain and swelling

2 point compression test :

- Left femoral vein : compressible with flow

- Left popliteal vein : not compressible

*on auscultation of lungs : lower zone crepitations of the right lung

INVESTIGATIONS
FBC :- Renal Profile :-

● Hb : 15.2g/dL (N) ● Urea : 4.1mmol/L (N)

● TWBC : 14.9 x 10^9 (H) ● Sodium : 135 mmol/L (N)
● Platelet : 214 (N) ● Potassium : 3.8 mmol/L (N)
● Chloride : 111 mmol/L (N)
● Creatinine : 99 mmol/L (N)
INVESTIGATIONS
● CXR : right lower zone consolidation
● Echo : RA and RV dilated (McConnell’s sign positive), D-shaped LV
● ECG : S1Q3T3 with depressed T V1-V6, sinus tachycardia
● USG Doppler left lower limb : left DVT (superficial femoral vein)
● CTPA : extensive bilateral PE-both main pulmonary artery
● D-dimer : 68.34 mcg/ml
● INR : 1.22
IMPRESSION

Pulmonary embolism secondary to deep vein

thrombosis
MANAGEMENT
● S/C Fondaparinux 7.5mg stat OD
● IV drip 3 pints normal saline/24 hour
● Aim INR 2-3
● Maintain SpO2 >98%
● For thrombophilia workout
● U/S abdomen - TRO occult malignancy/abdominal mass
● KIV refer vascular Serdang for thrombectomy/embolectomy if worsening
respiratory distress
● To start T.Warfarin after sending blood for thrombophilia screening
DISCUSSION
INTRODUCTION
● Venous thromboembolism (VTE) and PE is the third most common cause of
cardiovascular death after myocardial infarction (MI) and cerebrovascular
accidents (CVA).
● Many PEs are likely undiagnosed and calculating the true incidence remains
challenging.
● However, PE remains a significant cause of preventable in-hospital mortality.
● According JACC, the annual incidence rate of VTE ranges between 75 and
269 cases per 100,000 persons, as shown by studies in Western Europe,
North America, Australia, and southern Latin America.
In the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) trial
patients with PE had a range of signs and symptoms.

● Common signs were tachypnea (54%) and tachycardia (24%). The most common
symptoms were dyspnea, usually of onset within seconds, at rest or with exertion
(73%), pleuritic pain (44%), calf or thigh pain (44%), calf or thigh swelling (41%),
and cough (34%).
● With only 24% of patients presenting with tachycardia, the majority of patients
lacked one of the most common findings.
● Therefore, a high index of suspicion and assessment of risk factors are critical for the
recognition of pulmonary embolic events.
RESULT?