Major case presentation on Acute

Pulmonary Embolism with

Deep Vein Thrombosis
By
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.

LABORATORY INVESTIGATIONS:
CBC Patient value Normal value
RBC 5.20 3.8-4.8
millions/µl
WBC 12290 4000-
11000cumm
ESR (mm/hr) 90 M: < 10, F: < 20
MCV 77.1 80-100 fl
MCH 24.6 27-32 g/dl

URINE EXAMINATION:
• Albumin is present in traces.
• Prothrombin time (PT, INR)
Patient value 17.5 10-14 sec normal
range
Control value 13.9 -----do---
INR 1.30 -----do---

• D-DIMER TEST – 2588.46 ng/ml normal range - < 500 ng/ml

• Echo – Moderate pulmonary hypertension

RA/RV – mildly dilated
RV free wall hypokinesia

• Troponin –T: negative

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 12290 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.
• 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
 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.
• 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
S.N Brand Name Generic Name Dose Day
o 1 2 3 4 5 6 7

1. Inj. Lomoh s/c Enoxaparin 0.6ml Y Y Y Y Y Y Y

1-0-1

2. Tab.Clopitab A Clopidogrel 150mg Y Y

Aspirin 0-1-0

3. Tab. Atorsave Atorvastatin 20mg Y Y

0-0-1

4. Tab. Isonorm Isosorbide 30mg Y

SR mono nitrate 1-0-0

5. Tab. Nicostar Nicorandil 5mg Y Y

1-0-1

6. Tab. Metpure Metoprolol 25mg Y Y

XL 1-0-0

7. Inj. Pantodac Pantoprazole IV stat Y Y Y

8. Tab. Zolfresh Zolpidem 5mg Y Y
0-0-1

9. Tab. Warf Warfarin 0-0-1 Y Y Y Y Y Y Y

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