A C A S E P R E S E N TAT I O N O N

ACUTE PROXIMAL DEEP VEIN

THROMBOSIS OF LEFT LOWER
LIMB WITH ANEMIA

PRESENTED BY
K.N.SAI LEELA
Y17PHD0408
Internship activities
Department – Gastroenterology Cardiology
Cases collected- 25 cases collected:- 25
Patient counseling-25 patient counseling:- 25
DI:- 10 DI:- 5

Paediatrics
Cases collected:- 25
Patient counseling-25
DI:- 5
PATIENT DEMOGRAPHICS:
• NAME : MR.X
• AGE : 40 YEARS
• GENDER: MALE
• DOA : 27-01-2023
• DOD : 29-01-2023
• WARD: CARDIOLOGY
SUBJECTIVE EVIDENCE:
A patient Mr.x of age 40 years was admitted in the cardiology ward on 27-01-2021 with chief complaints of :
• Left lower limb swelling since 10 days up to thigh. (pitting type grade- I, 2 mm depth and immediate
rebound)
• Warmth and redness on the leg – present.
• Associated with presyncopeal attacks. ( Dizziness, lightheadedness, nausea)
Past medical history : not significant
Past medical history : not significant
Family history: not significant
Personal history: Takes mixed diet
Sleep and appetite – normal
Bowel and bladder- normal
Objective Evidence:
General physical examination: Complete blood picture report:
Test name Results Bio. Ref. Range
P+ I- C- C+ L- E+
Haemoglobin 5.5 gm% 13 –17 gm%
Peripheral smear: Twbc 15,910 cell/mm3 4.0 - 11.0 cell/mm3
Esinophilis 15% 1 – 5.0 %
• Microcytic hypochromic anemia
ESR 100 mm/hr 0 – 30 mm/hr
With peripheral esinophilia. PCV 21.5% 36 – 46 %
TRBC 3.30 millions/cumm 4.0 - 11.0x10x3
millions/cumm
MCV 65.2 fl 83 – 101 fl
MCH 16.6 pg 27 - 32pg
MCHC 25.5 gm/dl 31.5 - 34.5 gm/dl
Serum ferritin 16 ng/ml 20 – 250 ng/ml
TIBC 460mcg/dl 240 – 450 mcg/dl
Provisional diagnosis:
A suspection of acute proximal DVT of left lower limb with anemia.
Confirmational diagnosis:
Based on the subjective and objective evidence the patient was diagnosed with:
"ACUTE PROXIMAL DEEP VEIN THROMBOSIS OF LEFT LOWER LIMB WITH
ANEMIA"
Assessment:
The subjective evidence of left lower limb swelling since 10 days upto thigh, with
presyncopeal attacks and the objective evidence of complete blood picture, TIBC test, peripheral
smear and PICCLE examination reports strongly indicates "ACUTE PROXIMAL DEEP VEIN
THROMBOSIS OF LEFT LOWER LIMB WITH ANEMIA"
Risk factor : smoking since 12 months 2-3 cigarette/day
Medication chart:

s.no Drugs Day-1 Day-2 Day-3

1 Inj. Heparin 500u/hr iv​ -
2 Inj. Ceftriaxone 1gm iv 1-0-1​
3 T. ferrous ascorbate & folic acid 0-1-0​
4 Cap. Vit B complex 0-1-0​
5 Tab. Pantoprazole + domperidone​
(40mg+30mg) 1-0-0​
6 T. Acenocoumarol 2mg 0-0-1 (6pm)
-
Day wise report:
D AY- 2 :
D AY- 1 :
PAT I E N T I S C O N S C I O U S A N D
PAT I E N T I S C O N S C I O U S A N D
COHERENT
COHERENT

VITALS VALUES VITALS​ VALUES​

B.P 120/80 mmHg
B.P​ 100/80 mmHg​
PULSE 80 bpm PULSE​ 86 bpm​
RR 18 bpm RR​ 20 bpm​
Day- 3:
Patient is conscious and coherent. All vitals found to be normal. The patient has been discharged
with the following medications for 4 weeks and asked to review after 4 weeks.

Patient was discharged with

• T. cefixime 250mg oral BD
• T. ferrous ascorbate & folic acid oral OD
• Cap. Vit B complex oral OD
• T. acenocoumarol 2mg oral OD
• T. pantoprazol+domperidone 40/30mg oral OD

Review after 4 weeks

Patient counselling:
DO's:
Do moderate physical activities like walking for 30 mins per day.
Eat Iron rich foods like carrots, beetroot, grapes, green leafy vegetables (spinach,broccoli).
Eat food that are rich in vitamin C such as Orange, Kiwi, Strawberries.
Do foot exercise every half an hour- this helps keep blood moving while you sit or stand.
Limit sodium intake to 400 mg per meal.
Elevating your legs above heart level helps for blood movement . Use pillows to proper rise up your leg. If needed.
Don’ts:
Don’t cross your legs while sitting
Avoid refined and processed food.
Beware of the calcium intake because calcium decreases the iron absorption. Calcium foods like milk and cheese.
Avoid fibre food. It is also decrease the absorption of Iron.
Avoid sugary food. Such as sweets, canned drink, because they trigger inflammation and also cause weight gain.