DUMAG, ARIANNE CAMILLE T.

SEC B - GROUP 8
AM WARD (DR. Deduyo)

Date of Interview: May 12, 2023

Informant: patient & daughter
12 days confinement

I. GENERAL DATA
R.O, 58 years old, male, separated, unemployed, Filipino, Roman Catholic, born
on January 7, 1964 at Pasay City, admitted for the 3rd time last May 1, 2023 in Pasay
City General Hospital.

II. CHIEF COMPLAINT

Right leg painful swelling

III. HISTORY OF PRESENT ILLNESS

1 week PTA, patient experienced bipedal edema with non-moveable lump on the
anterior right lower leg, described as itchy and dry, pain comes and goes, no radiation,
aggravating factor is when walking or whenever there is pressure on the leg, alleviated
by elevation of leg, associated with easy fatigability but not associated with trauma,
fever, difficulty of breathing, and headache. No medication taken and no consultation
done.

3 days PTA, the lump increased in size, associated with aching, redness, heat,
and itchiness, with a pain scale of 8/10. Teleconsulation was done, the patient was
prescribed with Tramadol 325mg 2x a day, that gave temporary relief and pain scale was
4/10. Patient puts hot compress to minimize the pain.

Few hours PTA, still with the above symptoms, the patient experienced pain
whenever the lump was grazed with cloth, pain scale 10/10, also the patient wasn’t able
to move his right leg; he went to PCGH with subsequent admission.

IV. PAST MEDICAL HISTORY

Patient's claims to have complete childhood immunizations. No COVID 19
vaccination. He had no childhood illnesses such as chicken pox, mumps and measles.
Patient has been known hypertensive since 2019, maintenance medications
include Losartan 100 mg taken every morning and Amlodipine 10mg. Other medications
are Calcium carbonate 500mg, 1x a day, Sevelamer 800 mg, 2x a day, Ferrous sulfate,
 3x a day, and EPO IV every dialysis which is 2x a week. Patient is compliant with
medications.
History of blood transfusion, every dialysis session, 1 unit PRBC. History of mild
stroke in 2013. In 2022, he had Inguinal Hernia surgery .Diagnosed with CKD in 2021,
where dialysis started. Recent hospitalization were due to edema.
No allergies to food and drugs.

V. FAMILY HISTORY
Patient’s father died at 82 y/o due to cardiac arrest. Patient’s mother died at 60
y/o due to CAD. He is 4th born among 8 siblings, 1 sister died due to CKD and 1 brother
died nung bata pa, other siblings are apparently healthy. He has 4 children, 1 dies due to
endometrial cancer, others are apparently healthy. No known heredofamilial diseases
such as, arthritis, gout, psychiatric problem, seizures disorder, thyroid disease and
pulmonary tuberculosis.

VI. PERSONAL & SOCIAL HISTORY

The patient is married for 25 years, but live apart with his wife. The patient
finished up to 2nd year HS. He was a driver for 15 years. He lives in a well ventilated 1
bedroom apartment at Pasay City with her daughter, toilet is de buhos. Garbage is
collected 2x per day. Source of drinking water is mineral. No pets
Patient is non-smoker, occasional alcohol drinker. No history of illicit drug use. He
eats 3x a day with merienda, prefers meat and seldom eats vegetables. Drinks 1 coffee
per day, and drinks soda. He has about 6-7 hours of sleep per night. No exercise. Hobby
includes watching TV.

VII. REVIEW OF SYSTEMS

Constitutional: (-) Fatigue, (-) Chills, (-) Fever, (+) Weight Loss From 91 To 85
Kls 1-2 Months, (-) Weight Gain

Integumentary: (+) Dryness, (-) Rashes, (-) Itchiness, (-) Lumps, (-) Changes
In Color

Hair: (-) Increase Hair Fall, (-) Baldness, (-) Excess Hair

Head: (-) Headache, (-) Dizziness, (-) Tenderness, (-) Trauma

Eyes: (+) Blurred Vision, (+) Use Of Glasses/Lenses, (-) Eye Pain, (-)
Redness, (-) Double Vision, (-) Photalgia, (-) Lacrimation

Ears: (-) Hearing Problem , (-) Ear Pain, (-) Itching, (-) Discharge
 Mouth And Throat: (-) Dysphagia, (-) Hoarseness, (-) Sore Throat, (-)
Odynophagia, (-) Use Of Dentures, (-) Bleeding Gums, (-) Toothache, (-) Mouth Sores

Neck: (-) Pain, (-) Lump, (-) Stiffness

Breast: (-) Pain, (-) Lump, (-) Discharge

Respiratory: (-) Cough, (-) Sputum, (-) Hemoptysis, (-) Dyspnea, (-) Wheezing,
(-) Rales

Cardiovascular:
Renal: (-) Polyuria, (-) Dysuria, (-) Nocturia, (+) Urgency, (-) Gross Hematuria,
(-) Retention, (-) Flank Pain, (-) Reduced Caliber Or Force Of Urinary Stream, (-)
Dribbling, (-) Straining, (-) Hesitancy

Genitalia: (-) Pain, (-) Swelling, (-) Ulcers, (-) Itching, (-) Discharged

Peripheral Vascular: (-) Leg Cramps, (-) Varicose Veins

Musculoskeletal: (-) Back Pain, (-) Muscle Pain, (-) Joint Pain, (-) Joint Stiffness,
(-) Joint Swelling,

Neurologic: (-) Paralysis, (-) Numbness, (-) Tremors, (-) Memory Loss, (-)
Seizures, (-) Changes In Mood

Hematologic: (-) Pallor, (-) Easy Bruising, (-) Bleeding

Endocrine: (-) Heat/Cold Intolerance, (-) Excessive Sweating, (+) Polydipsia, (-)
Polyphagia

Psychiatric: (-) Nervousness, (-) Hallucinations, (-) Depression, (-) Anxiety

VIII. COMPLETE PHYSICAL EXAMINATION

General Survey
Patient is medium built, acutely ill, well developed, conscious, coherent,
cooperative, ambulatory, and not in cardiorespiratory distress.

Vital Signs Anthropometrics

BP HR HT 5’5
180/100 mmHg 88/min

RR 23/min T 36.5℃ WT 85 kgs

Integument
The skin is brown in color, warm, dry to touch, has good skin turgor, no superficial
blood vessels, with some hyperpigmentation. Hair is thin, soft, and sparse. CRT is less
than 2 seconds.

HEENT
Cranium The head is midline in position with no abnormal head
movement. The skull is normocephalic, oval in shape and
symmetrical. There are no visible lesions, scales, and
deformities.The hair is gray in color with some thinning. The
cranium is normocephalic and symmetrical. There is no
tenderness, swelling, abnormal prominence, and
depression. The hair is smooth and dry.

Face The face is symmetrical, skin is brown in color, soft and

smooth with no lesions, and with some hyperpigmentation.

Eyes Eyebrows and eyelashes are black in color. Eyelashes are

short and present in both upper and lower eyelids.
Conjunctiva is pink in color. Sclera is icteric. Iris is round
and brown in color. Pupils are round and symmetrical, can
accommodate, reactive to both direct and indirect light
reflex.

Ears Symmetrical, auricle normal size, patent ear canal. No

lesions, nodules, deformities

Nose Nose is symmetrical and pointed. No alar flaring. Turbinates

are pinkish, no edema, no swelling, and no secretions.

Mouth Lips are pink and symmetrical. Buccal mucosa and gums
are pinkish, moist, with no lesions. Teeth are yellowish
without complete set of teeth. Tongue is pinkish in color, in
midline position upon protrusion and retraction, and can
move without difficulty. No tremors, no coating, no lesions
noted. The hard and soft palate is pinkish, no masses,
lesions and bony protuberance.

Neck Skin is fair in color. Normal in size, symmetrical with full

range of motion . Trachea is in the midline. Thyroid is not
visible but palpable with no tenderness, moves with
deglutition.
Chest & Lungs
● Anterior Part
○ Inspection
■ Skin
● Brown/fair in color
● No visible scars noted
● No lesions, no masses
● No tenderness
■ Chest wall
● Chest is symmetrical with no bony deformities
● No abnormal retractions of intercostal spaces
● No narrowing or widening of the intercostal spaces
○ Palpation
■ Anterior chest
● Symmetrical in expansion
● Tactile fremitus is not performed
○ Percussion
■ Resonant all over
○ Auscultation
■ Normal breath sounds
● Posterior Part
○ Inspection
■ Skin
● Brown/fair in color
● No lesion
● Some hyperpigmentation
○ Palpation
■ Symmetrical in expansion
■ No tenderness, No masses
○ Percussion
■ Resonant all over
○ Auscultation
■ Normal breath sounds

Cardiovascular
​Upon inspection, there is visible neck vein distension, no bulging nor depression
of the thorax with Adynamic precordium. Carotid artery pulses are palpable, strong and
bounding. Radial artery pulses not palpable. Right & Left brachial pulses are not
palpable. Femoral artery not palpated. Adynamic precordium, apex beat at 5th LICS
MCL. No heaves, thrills and lifts. Apex beat is at the 5th intercostal space left
midclavicular line. S1 is loudest at the apex and S2 is loudest at the base. No S3, S4,
and extra heart sounds.
Abdomen
● Inspection:
○ Abdominal circumference at the level of the umbilicus is 109 cm.
○ It is brown, globular, and symmetrical bulging
○ Visible scar below umbilicus from previous umbilical hernia
○ No visible lesions, no superficial veins, and striae
○ The umbilicus is inverted without visible pulsations or peristalsis
● Palpation:
○ Abdomen is rigid
○ No tenderness and no appreciated masses
○ The liver, spleen, abdominal aorta, right and left kidneys are not
palpable
● Test for costovertebral angle tenderness not performed due pain reported
by patient
● Percussion:
○ Abdomen is generally dull in all quadrants
● Auscultation:
○ Bowel sound: 12 cpm (Hypoactive)
○ No bruit over the abdominal aortic vessel, right and left renal
arteries and right and left iliac arteries.
○ No borborygmi, peritoneal friction rub and succussion splash.
● Special Examinations:
○ Test for Ascites
■ (+) Fluid wave test
■ (-) Shifting dullness

Extremities
● Cervical Spine – has no gross deformities, no lesions, no nodules, no
tenderness, heat, crepitus; ROM- flexion (+), extension (+), rotation (+), lateral
bending (+)
● Hands & Fingers - No deformities, nodes, bogginess on both thumbs; Normal
color, no clubbing of fingers;Right hand and fingers (+) Edema; ROM - flexion
(+), extension (+), abduction (+), adduction (+), thumb in abduction (+), thumb in
adduction (+), apposition (+)
● Wrist Joint - No deformities, bogginess, masses, and tenderness with thumb;
Palpable radial and ulnar distal ends; Left wrist ROM- dorsiflexion (+), palmar
flexion (+), medial & lateral deviation (+) ; Right wrist ROM dorsiflexion (-),
palmar flexion (-), medial & lateral deviation (-)
● Forearm- Normal color, no muscle and bone deformities on both forearm and
Right forearm (+) Edema - pronation (+), supination (+); R= 37cm, L= 28 cm
 ● Elbow- Palpable olecranon process, lateral and medial epicondyle; no nodules,
and no tenderness ; ROM- flexion (+), extension (+), pronation (+), supination
(+); R=39 cm, L=29 cm
● Upper arm- No humeral deformity on both upper arm ; No tenderness of biceps
and triceps on left upper arm ; Right Upper arm (+) Edema
● Shoulder- Palpable sternum, sternoclavicular joint, acromion, no swelling and
tenderness of the phalanges; ROM -flexion (+), extension (+),abduction (+),
adduction (+);
● Hip Joint – no visible lesions and no gross deformities. No tenderness, swelling
or nodules noted. ROM – flexion (+), extension (+), adduction (+), abduction (+),
internal rotation (+), external rotation (+)
● Knee Joint – no visible lesion or gross deformities. Patella is palpable. No
tenderness, nodules on both knee joint and (+) swelling on right knee .Left
knee ROM – flexion (+), extension (+), Right knee Joint ROM : flexion (-),
extension (-) legs are asymmetrical
● Ankle – visible lesions, scars and no gross deformities. (+)edema on right
ankle. (-) Clubbing of nails (-), pink nail bed, nail plate abnormality (-). ROM –
inversion (+), eversion (+), dorsiflexion (+), and plantar flexion (+)

Neuro Exam
Cerebrum: The patient was conscious, coherent, and cooperative. He was oriented as
to person, time and place. He was able to demonstrate object recall, had no difficulty to
follow simple and complex commands, and able to do calculation, intact immediate,
recent and remote memory.
Cerebellum: Patient was able to execute a finger-nose test.
Cranial Nerves:
CN I Intact

CN II Both pupils are equally reactive to light and

accommodation.

CN II / III Pupils are equally round and respond to direct light and
consensual stimuli

CN III / IV / VI Patient has full extraocular muscle movements

CN V Able recognize sensations of pain and light touch

bilaterally on the face, able to demonstrate normal and
force in the muscle of mastication

CN VII Able to demonstrate different facial expression

CN VIII Patient was able to repeat words whispered to her and

able to localized the sound.
 CN IX / X Uvula is at the midline. Gag reflex was not assessed,
Both sides of pharyngeal wall are symmetrical, no
hoarseness of voice noted.

CN XI No fasciculation, tremors or atrophy noted. Patient was

not able to shrug her shoulders symmetrically.

CN XII Tongue is at the midline and symmetrical when

protruded, no atrophy nor involuntary movement
observed.

Motor Function: No muscle atrophy/hypertrophy, no fasciculation noted. There is no

rigidity and involuntary muscle movement noted. Patient has good muscle tone.
Reflexes: DTR are normal. Biceps, triceps, knee and ankle are 2+. Patient is negative
for Babinski.
Sensory: Intact sensation for pain, crude touch and position sensation for both upper
and lower extremities.
Meningeal: Brudzinski, Kernig’s sign, and nuchal rigidity are all negative.

IX. SALIENT FEATURES

● Bipedal edema
● Swelling on the anterior right lower leg (itchy, dry, on and off non radiating pain)
○ Aggravated by walking
○ Relieved by elevating the legs
● Lump (red, warm to touch, painful and itchy)
● ESRD 2021
● On dialysis twice a week
● Hypertensive since 2019
● Mild stroke last 2013
● Frequently admitted due to edema
● Family history of cardiovascular disease
● Family history of CKD
● Occasional alcoholic drinker
● No exercise
● Weight loss from 91 to 85 kg 1-2 months
● Dryness of the skin
● Icteric sclera
● Visible neck distention
● Radial and brachial pulses not palpable
● Hypoactive bowel sounds (12)
● (+) fluid wave test
● (+) edema on right arm, forearm, hands and fingers
X. PRIMARY DIAGNOSIS & DIFFERENTIAL DIAGNOSIS
PRIMARY IMPRESSION: DEEP VEIN THROMBOSIS
Basis:
● Swelling
● Redness
● Pain
● Heat
● Tenderness

Differential DIagnosis
RULE IN RULE OUT

Cellulitis (+) Swelling (-) Fever

(+) Redness (-) Body malaise
(+) Pain (-) Chills
(+) Tenderness (-) Regional
(+) Warm to touch lymphadenopathy
(-) Skin looks pitted
· Leg is the most common (-) Red streaks from the
site original site of cellulitis
· Common in
immunocompromised · No history of trauma or
patients breach in the skin

Superficial (+) Warm to touch (-) Palpable, indurated,

Thrombophlebitis (+) Tenderness cordlike, tender,
(+) Pain worsens with subcutaneous venous
added pressure segment
(+) Redness (-) Darkening of the skin
(+) Swelling over the vein
(+) Obesity (-) Varicose veins
(-) Similar prior episodes
(-) Tobacco use
(-) Family history of blood
coagulopathies

Peripheral Arterial (+) pain (-) Trauma

Disease (+) ache
XI. PATHOPHYSIOLOGY & EPIDEMIOLOGY

Pathophysiology
● According to Virchow's triad, the following are the main pathophysiological
mechanisms involved in DVT:
○ Damage to the vessel wall
○ Blood flow turbulence
○ Hypercoagulability
● Thrombosis is a protective mechanism that prevents the loss of blood and seals
off damaged blood vessels. Fibrinolysis counteracts or stabilizes thrombosis. The
triggers of venous thrombosis are frequently multifactorial, with the different parts
of the triad of Virchow contributing in varying degrees in each patient, but all
result in early thrombus interaction with the endothelium. This stimulates local
cytokine production and causes leukocyte adhesion to the endothelium,
promoting venous thrombosis. Depending on the relative balance between the
coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is
commonest in the lower limb below the knee and starts at low-flow sites, such as
the soleal sinuses, behind venous valve pockets.
● A potential correlation between DVT and atherosclerosis (AS) has been
proposed. The endothelial dysfunction involved in the pathophysiological
mechanism of DVT would potentially result in AS. Accordingly, a greater risk of
subsequent AS in patients with DVT is predicted.

Epidemiology
● WORLDWIDE
○ The exact incidence of DVT is unknown because most studies are limited
by the inherent inaccuracy of clinical diagnosis.
○ Existing data that probably underestimate the true incidence of DVT
suggest that about 80 cases per 100,000 population occur annually.
○ Approximately 1 person in 20 develops a DVT in the course of his or her
lifetime.
○ Deep venous thrombosis usually affects individuals older than 40 years.
○ The male-to-female ratio is 1.2:1, indicating that males have a higher risk
of DVT than females.
○ 3rd most frequent cardiovascular disease
○ 100-200 per 100000 individuals
■ 40% - DVT
■ 60% - PE
○ Untreated proximal DVT is associated with 30-50% risk for PE, and 12%
mortality rates

● PHILIPPINES
○ incidence of DVT in ICU patients is 20.7%
XII. DIAGNOSTICS
● Venography
○ Venography is considered the diagnostic standard for lower extremity
DVT. It is a procedure where contrast material is injected through a
catheter in a vein to help visualize the internal structures by using x-rays.
The test is used to identify and locate thrombi (blood clots) in the veins of
the extremity that is affected. Due to its disadvantages like potential
complications of contrast venography such as nephrotoxicity (secondary
to contrast dye), bleeding complications from the venous puncture, and
postprocedure phlebitis it is rarely used today.

● Venous Duplex Scan

○ A Venous Duplex Scan is a type of dedicated ultrasound to look at the
venous system. The ultrasound uses sound waves to see the veins and
evaluate blood flow within them. Its overall sensitivity: proximal 94.2,
distal 63.5% and overall specificity of 93.8%.

○ Duplex Ultrasound Criteria for Acute DVT

■ Loss of compressibility
● Thrombus acts as a space-occupying lesion in the involved
venous segment
● The single most reliable finding for differentiating between
thrombosed and Normal veins.
■ Absence of blood flow in involved segment
● Thrombus obstruct venous return and absent spectral
display.
■ Venous Dilatation
● Fully obstructive thrombus is composed of fibrin mesh that
takes up more volume than blood.

● D-Dimer
○ A D-dimer test is a blood test that checks for blood-clotting problems. This
test measures the amount of D-dimer, a protein the body makes to break
down blood clots. A negative test can help exclude venous
thromboembolism.

XIII. MANAGEMENT
A. Non-Pharmacological Management
○ Goals: Prevention of pulmonary embolism and extension of the thrombus,
reduce the risk of associated cardiovascular events events, improve limb
symptoms, prevent progression to critical ischemia,and preserve limb viability
○ Risk factor modification: Blood pressure control
○ Supportive: Feet care, elastic supports should be avoided, regular exercise
(walk until nearly maximum claudication discomfort is experience, and then rest
until symptoms resolve before resuming ambulation)
○ Revascularization is usually indicated for patients with disabling, progressive or
severe symptoms despite medical therapy and for those critical limb ischemia

B. Pharmacological Management
○ Unfractionated Heparin- Initial IV bolus (80 U/kg or 5,000 U) by continuous
infusion (initially 18U/kg/h or 1,300 U/h) with APTT monitoring (Grade 1C).
○ Low Molecular Weight Heparin (LMWH)
■ - LMWH SC once or twice daily, as an outpatient if possible (Grade1C) or
as an inpatient if necessary (Grade 1A), rather than treatment with IV
UFH.
■ - In patients with acute DVT and severe renal failure, suggest UFH over
LMWH (Grade 2C)
○ Fondaparinux- Fondaparinux by subcutaneous injection once daily
○ Thrombolysis
○ Thrombus Removal Device
○ IVC Filter
○ Vitamin K Antagonist – Warfarin NOACS or DOACS

○ Primary therapy consists of clot dissolution with pharmacomechanical therapy

that usually includes low-dose catheter-directed thrombolysis. This approach is
reserved for patients with extensive femoral, iliofemoral, or upper extremity DVT.
The open vein hypothesis postulates that patients who receive primary therapy
will sustain less long-term damage to venous valves, with consequent lower rates
of postthrombotic syndrome.

C. Secondary Prevention
○ Anticoagulation or placement of an inferior vena caval (IVC) filter constitutes
secondary prevention of VTE. In 2016, the FDA approved a new retrievable IVC
filter that is inserted at the bedside with ultrasound visualization of the femoral or
internal jugular vein (Angel® Filter) but without the need for any fluoroscopic or
other radiological imaging.

○ For patients with swelling of the legs when acute DVT is diagnosed, below-knee
graduated compression stockings may be prescribed, usually 30–40 mmHg, to
lessen patient discomfort. They should be replaced every 3 months because they
lose their elasticity. However, prescription of vascular compression stockings in
asymptomatic newly diagnosed acute DVT patients does not prevent the
development of postthrombotic syndrome.
XIV. COMPLICATION & PROGNOSIS
Complications
● Thrombosis extension
● Pulmonary embolism
● DVT recurrence
● Post Thrombotic Syndrome
○ Most frequent DVT complication

Prognosis -
● Many DVTs will resolve with no complications.
● Post-thrombotic syndrome occurs in 43% of patients two years post-DVT
(30% mild, 10% moderate, and severe 3%).
● The risk of recurrence of DVT is high (up to 25%).
● Death occurs in approximately 6% of DVT cases and 12% of pulmonary
embolism cases within one month of diagnosis.
● Early mortality after venous thromboembolism is strongly associated with
the presentation of pulmonary embolism, advanced age, cancer, and
underlying cardiovascular disease.

XV. CONCEPT MAP

REFERENCES:

Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (2022). In
Harrison's Principles of Internal Medicine (21st ed.,). essay, McGraw-Hill Education.