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DEEP VEIN

THROMBOSIS
Abdul Rahim Bin Mohamad Nor
C 111 10 871
SUPERVISOR
Prof.dr.Peter Kabo,PhD,SpFK,SpJP(K),FIHA,FASCC

PATIENTS IDENTITY

Name
: Mrs. S
Age
: 58 y.o.
MR
: 049115
Admitted : November 24th , 2015

HISTORY TAKING

Chief complaint
Swelling on the right leg

Present illness history


Occurs

since one week ago, the patient


complained of right leg slowly beginning to swell
with pain and cramps. No cyanosis, patients can
still feel if his feet touched. No SOB, no DOE, no
orthopnea and no Paroxysmal Nocturnal Dyspnea.

HISTORY TAKING

Past medical history


2010 patient were diagnosed with hypertension

and regularly control with drugs.


History of heart disease denied.
History DM denied
History of malignant diseases: Carcinoma Cervix
History of the same disease in the family does not

exist.

RISK FACTOR

Aging
Malignancy

PHYSICAL EXAMINATION

General state :
Moderate illness/well nourished/ conscious

Vital status
Blood Pressure : 130/80 mmHg
Pulse Rate : 90 bpm (regular)
Respiratory Rate
: 20 tpm
Temperature : 36,5 0C (axilla)
BW

: 50kg
BH
: 151cm
IMT : 21.91

PHYSICAL EXAMINATION

Head: anemic (-) icteric (-)


Neck : JVP R+1 cmH2O (300)
Chest :
Inspection

: symmetry left = right


Palpation : mass (-), no tenderness
Percussion : sonor left = right
Auscultation
: vesicular, ronchi -/- wheezing -/-

PHYSICAL EXAMINATION

Cor :
Inspection

: ictus cordis not visible

Palpation

: ictus cordis not palpable, thrill (-)

Percussion :
dull, Upper border 2nd ICS linea parasternalis sinistra,
Right border 4th ICS linea parasternalis dextra, Left
border 5th ICS linea medioclavicularis sinistra
Auscultation: heart sound I/II pure, regular, murmur (-)

PHYSICAL EXAMINATION

Abdomen :
Inspection

: flat, follows breath movement

Auscultation: peristaltic (+), normal


Palpation

: liver and spleen not palpable

Percussion : tympani

Extremities

Swelling on the right leg with pain


Pitting Edema
Warm(+)
Homans sign positif

LABORATORIUM (November, 1

st ,

2015

HEMATOLOGY

RESULT

NORMAL VALUE

WBC

19,29 x 103 /mm3

4.0-10.0 x 103

RBC

3,96 x 106/mm3

4.0-6.0x106

HGB

10,5 g/dL

12-16

MCH

21,5 pg

26,5-33,5

MCHC

31,7 gr/dL

31,5-35

HCT

31,4

37-48

PLT

486 x 103/mm3

150-400 x 103

Ureum

54

10-50 md/dL

Creatinin

1,2

<1.3

Na

137

136-145 mmol/l

4,1

3.5-5.1 mmol/l

Cl

110

97-111 mmol/l

PT

17,4

10-14 detik

INR

1,45

APTT

36,5

22.0-30.0 detik

D Dimer

3,98

< 0,5

ELECTROCARDIOGRAPHY
(November 1st 2015)

Rhythm: Sinus rhytme


Frequence: 76 bpm
Axis: normoaxis
P wave: 0.04 sec
P-R interval: 0.1 sec
QRS interval: 0.1 sec
ST segment: normal

Conclusion : Sinus rhytme, normoaxis, heart rate 76 bpm.


ECG NORMAL

Echovascular
Blood flow from
distal to proximal is
not flowing well with
thrombus in
Common Femoral
Vein and Right
Popliteal vein.
CONCLUSION:
Deep Vein
Thrombosis

Resume
Women 58 yo came with Edema on right leg occurs since one

week ago, the right leg slowly beginning to swell, pain(+) and
cramps(+). History of hypertension(+) on treatment,
Malignancy(+): Carcinoma Cervix. Physical examination on lower
extremities: Edema on the right leg, warmt(+). Homans sign(+).
Risk factor: Carcinoma Cervix, Wells Score: +2
Laboratory finding: WBC: 19,29, PLT: 429000 , PT: 17,4, APTT:

36,5, INR: 1.45, D-Dimer: 3,98.


Echo vascular: Blood flow from distal to proximal is not flowing

well with thrombus in Common Femoral Vein and Right Popliteal


vein

DIAGNOSIS
Deep Vein Thrombosis

TREATMENT
IVFD NaCl 0.9% 500cc/24h/intravena
Alpentin 100 mg/24h/oral
Simarc 2 mg/24h/oral
MST 15 mg/24h/oral

DISCUSSION

DEFINITION

Deep vein thrombosis (DVT) refers to


the formation of one or more blood clots
in one of the bodys large veins, most
commonly in the lower limbs. The clot
can cause partial or complete blocking
of circulation in the vein

ANATOMY OF DEEP AND


SUPERFICIAL VEINS

ETIOLOGY / RISK FACTOR

PATHOGENESIS

Three mechanisms are involved in


the pathogenesis of venous
thrombosis (Virchows triad), they
are:
venous stasis,
injury to the venous wall,
hypercoagulable states.

CLINICAL FEATURES

A DVT most commonly develops in a deep vein


below the knee in the calf. Typical DVT
symptoms include:
Pain and tenderness of the calf.
Swelling of the calf.
Colour and temperature changes of the calf. Blood

that would normally go through the blocked vein is


diverted to outer veins. The calf may then become
warm and red.
Sometimes there are no symptoms and a DVT is only
diagnosed if a complication occurs, such as a
pulmonary embolus.

Edema, principally unilateral, is the most

specific symptom.
Leg pain occurs in 50% of patients, but
this is entirely nonspecific. Pain can
occur on dorsoflexion of the foot
(Homans sign).
Pratt's sign: Squeezing of posterior calf
elicits pain.

DIAGNOSIS

Well score

D-Dimer
D-Dimer, a byproduct of brin degradation that can be

measured in a peripheral blood sample, is highly sensitive


for the diagnosis of DVT and/or acute PE.
Because D-dimer may also be elevated in many other

conditions (such as cancer, inammation, infection and


necrosis), a positive test result is not specic for DVT.
Thus, a normal D-dimer value can help exclude the

presence of DVT, but an elevated level does not conrm


the diagnosis.

Venous compression duplex


that is 95% sensitive for the diagnosis of

symptomatic DVT in a proximal vein but


only.
This technique uses real-time ultrasound
scanning to image the vein and pulsed
Doppler ultrasound to assess blood ow
within it.
Criteria used for diagnosis of DVT with
duplex ultrasonography include the inability
to compress the vein with direct pressure,
direct visualization of the thrombus, and
absence of blood ow within the vessel.

ALGORITHMA OF
DIAGNOSIS

TREATMENT

The aim of treatment of VTE is to reduce


morbidity and mortality.
This is achieved by optimal therapy to
prevent thrombus extension and
embolisation.
The mainstay of therapy is
pharmacological.
Adjunct therapies include mechanical
devices like filters and stents.

INITIAL TREATMENT OF
DVT
In clinically suspected DVT, treatment with UFH or

LMWH should be given until the diagnosis is


excluded by objective testing
The regimen for the administration of iv UFH is as
follows
Baseline APTT, PT, FBC, renal profile, liver function test

and thrombophilia screen


Initial dose of iv bolus UFH 80 IU/kg followed by
maintenance infusion at 18 IU/kg/hr.
Check APTT at 6, 12 and 24 hours. The target APTT ratio
is 1.5 to 2.5. This must be achieved in the first 24 hours
and maintained thereafter.
Start warfarin therapy at 5 mg on the first 2 days.
Thereafter adjust daily dose according to INR.
Check platelet count from day 3 till the end of second
week.
Discontinue heparin once target INR (2.0 - 4.0) is
achieved on 2 consecutive days.

MANAGEMENT OF IV
UFH
Initial dose
80 IU/kg bolus, then 18
IU/kg/hr
APTT < 35 s (<1.2x control)

80 IU/kg bolus, then


increase
rate by 4 IU/kg/hr

APTT 35 to 45 s (1.2 to 1.5x


control)

40 IU/kg bolus, then


increase
Infusion rate by 2 IU/kg/hr

APTT 46 to 70 s (1.5 to 2.3x


control)

No change

APTT 71 to 90 s (2.3 to 3x
control)

Decrease infusion rate by 2


IU/kg/hr

APTT >90 s (>3x control)

Hold infusion for 1 hour,


then decrease
Infusion rate by 3 IU/kg/hr

SUBCUTANEOUS UFH

effective alternative to intravenous UFH for the


initial management of DVT
The regimen for the administration of
subcutaneous, UFH includes an
Initially, intravenous bolus of 5000 IU followed by

subcutaneous injections of 15,000 to 20,000 IU 12 hourly


This is monitored by the APTT with the mid-interval APTT
maintained between 1.5-2.5 times the control

LMWH recommended
LMWH recommended Treatment
Enoxaparin (Clexane)

1 mg/kg twice
daily

Nadroparin
(Fraxiparine)

0.1 ml/kg twice


daily

Nadroparin (Fraxiparine 0.1 ml/kg once


Forte)
daily
Tinzaparine (Innohep)
175 units/kg
once daily

MAINTENANCE TREATMENT
OF DVT

Following initial heparinisation in patients with


DVT, maintenance of anticoagulation with oral
anticoagulants is recommended
Following discharge-followed up within a week
with a repeat INR.
If the INR remains within therapeutic range, the
same dose is maintained and the next follow-up
will be 2 weeks later
More frequent visits are required if therapeutic INR
is not achieved

DURATION OF
THERAPY
Time
3 to 6 months

Event
first event with reversible or
time-limited risk factor
(Surgery, trauma,
immobility, oestrogen use)

= 6 months

idiopathic VTE, first


event

12 months to
lifetime
- first event with
cancer
until resolved

anticardiolipin antibody
- antithrombin deficiency
- recurrent event, idiopathic
or with thrombophilia

THANK YOU