DEEP VEIN THROMBOSIS

GADIS SABRINA TOBO

SUPERVISOR
.............................................
PATIENTS IDENTITY
Name : Ms. D
Age : 46 years old
Sex : Female
Religion : Islam
Reg. Number : 781355
Address :Tamengundur Street
Polman
HISTORY TAKING
Chief complaint
Swelling in the lower limb right
Present illness history
Felt since 3 days after admission, the patient
complained of swelling in the lower limb right.
Swelling began to grow slowly, pain (+), bluish
toe (-), patient can still feel when touched.
Patient had a history of stroke one year ago and
weak on the left side of the body. History of
swelling in the lower limb did not exist. History
of the same disease in the family does not exist
HISTORY TAKING
Past medical history
Patient had a history of stroke one year

ago and weak on the left side of the body.

Had a history of ovarian cysts since
4 months ago but did not do the
treatment.
History of hypertension denied
History of diabetes mellitus denied
RISK FACTOR
Histroy Family
No one in the family has this disorder
PHYSICAL EXAMINATION
General state :
Moderate ill/good nutrition/compos mentis
Vital status
Blood Pressure : 120/80 mmHg
Pulse Rate : 80 tpm (reguler)
Respiratory Rate : 18 tpm
Temperature : 36,5 0C (axilla)
 PHYSICAL EXAMINATION
Head :
Eyes : Anemic (+), Icterus (-)
Lips : Cyanosis (-)
Neck : Lymphadenopathy (-), DVS R+1 cmH 2O

Chest
Inspection : Symmetrical left=right,
normochest
Palpation : Epigastric tenderness (-), massa (-),
vocal fremitus left = right
Percussion : Sonor
Auscultation : Breath Sound vesicular, Additional
Sound: Rh -/-, Wh -/-
 PHYSICAL EXAMINATION
Heart
Inspection : Ictus cordis invisible
Palpation : Ictus cordis impalpable
Percussion : Deaf, impress size normal.
Border-right: right linea
parasternalis, Border-left: left linea
medioclavicularis
Auscultation : Heart sound S1,S2 neutral,
regular, noisy (-)
PHYSICAL EXAMINATION
Abdomen :
Inspection: Convex, in accordance breath motion
Auscultation: Peristaltic (+), normal sound
Palpation: tumor mass palpable mobile solid mass the
size of 5x5cm Liver and spleen are not palpable
Percussion: Timpani (+), Ascites (-)

Extremities :

edema in the right foot, dorsalis pedis artery pulsation,

tibialis posterior, and right popliteal palpable strong
 Electrocardiography Examination
Laboratory Examiantion (4-2-2017)
LABORATORIUM (November, 1 st , 2015 )
ELECTROCARDIOGRAPHY
(November 1st 2015)
The Dopplers USG of lower limb
Image :
Inferior dextra extremity venous blood flow
substandard, seen thrombus as high as
Common Femoral and Popliteal.
Inferior extremity blood flow smooth.
DIAGNOSIS
Deep Vein Thrombosis of Lower Extremity
 TREATMENT
IVFD NaCl 0.9% 500cc/24hours/intravena
Lanzoprazole 30mg/24 hours/intravena
Ceftriaxone 2 gr/24hours/intravena
Ardium tab/12 hours/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.
 Stasis disrupts laminar flow and brings platelets
into contact with the endothelium. This allows
coagulation factors to accumulate and retards the
VENOUS STASIS influx of clotting inhibitors. Factors that slow
venous flow and induce stasis include
immobilization

including resistance of coagulation factor V to

HYPERCOAGULABLE activated protein C, a prothrombin gene mutation,
STATES and inherited deciencies of antithrombin, protein
C, and protein S.

Vascular damage, either by external injury or by

intravenous catheters, can denude the
endothelium and expose subendothelial collagen.
INJURY TO THE Exposed collagen acts as a substrate for the
VENOUS WALL binding of von Willebrand factor and platelets and
initiates the clotting cascade, leading to clot
formation.
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
specic symptom.
Leg pain occurs in 50% of patients, but
this is entirely nonspecic. 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, inflammation,
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 flow
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 flow
within the vessel.
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 prole, 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 rst
24 hours and maintained thereafter.
Start warfarin therapy at 5 mg on the rst 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.
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
DURATION OF THERAPY
Time Event
3 to 6 months rst event with reversible or
time-limited risk factor
(Surgery, trauma,
immobility, oestrogen use)
= 6 months idiopathic VTE, rst
event
12 months to - anticardiolipin antibody
lifetime - antithrombin deciency
- recurrent event, idiopathic
- rst event with or with thrombophilia
cancer
until resolved
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