DVT

Yosefin Eka
Pembimbing : dr. Anik W., Sp. PK (K)
 Summary of Database
Female/63 y.o.
Autoanamnesis
Chief Complaint:
Left leg swelling
History of Present Illness:
-She complaint for left leg swelling since 2 days before
admission. The swelling from the soles of the feet to the
thight. Her feet felt warm, redness, and also pain.
-The patient had bedridden for 4 months because he had
fallen from bathroom, and her right leg fractured, and she
refused the doctor for operation
-History of fever (-), cough (-), shortness of breath (-), COVID-
19 infection (-)
 Summary of Database
Past Medical History:
-She was diagnosed with DM since 1 year ago because she felt
malaise and then she checked the random blood sugar >400 mg/dL.
The doctor gave her insulin but after few months she didn’t used the
insulin anymore and didn’t control to the doctor.
-She has hypertension (+), and hypercholesterol (+) but didn’t
consume drugs.
-History of allergy (-), epilepsy (-), asthma (-)

Family History:
There is no family history of the similar disease.

Social History:
• She is a housewife and there was no history of smoking and alcohol
drinking
 PHYSICAL EXAMINATION
General status Moderate ill, GCS : 4-5-6; Sat O2. 98% on 2 lpm NC;
BW : 70 kg ; Height : 165 cm ; (BMI 25. 7 overweight)
Vital sign BP : 137/87 mmHg HR : 98 bpm regular strong
RR : 20 tpm Tax : 36.7°C
Head & Neck Conjunctiva Anemic (-/-), Sclera Icteric (-/-),
JVP R + 3 cmH2O;
Thorax Pulmo : Symmetrical, retraction (-), Rh-/-; Wh -/-
-/- -/-
-/- -/-
Cardiac : ictus at 5th ICS left MCL, single S1/S2, murmur (–),
gallop (-)
Abdomen Soefl, bowel sound (+/+), traube space thympani
(+)

Extremities warm, edema -/-; atrophy -/-;

-/+ +/-
left leg hyperemia (+), and warm (+) ; Homan’s
sign +
CBC 14/09 20/09 Reference

Hb 14,30 12,20 11,4 - 15,1 g/dL

RBC 5,37 4,49 4,0 - 5,0 x 106/µL

WBC 14,44 ↑ 12,33 ↑ 4,7 - 11,3

x 103 /µL
NLR 6.00
Ht 42,40 37,40 38 - 42%
ALC 1.94
PLT 165 230 142 – 424
x103/µL
MCV 79,00 83,30 80 – 93 fL
MCH 26,60 27,20 27 – 31 pg
MCHC 33,70 32,60 32 – 36 g/dL
RDW 13,90 13.50 11,5 - 14,5 %
Diff 1/-/-/81/13/5 1/-/81/12/6 0-4/0-1/51-
67/25-33/2-5
• Neutrophil absolute 11.64 x 10^3
 FH 14/9 18/9 20/9 Reference
PT Patient 10,50 9,4 - 11,3
Control 10,8
INR 1,01 < 1,5
APTT Patient 28,60 24,6 - 30,6
Control 26,0
Fibrinogen 341,1 389,2 154,3 - 397,9
D-dimer 3,31 ↑ 3.02 ↑ ≤ 0,5 mg/L
 14/9 20/9 Reference
AST 10 (11:47) 0 – 40 U/L
ALT 7 (11:47) 0 – 41 U/L
Albumin 3,85 3.5–5.5 g/dL
16.6–48.5
Ureum 53,1 ↑
mg/dL
Creatinine 0,60 < 1.2 mg/dL
eGFR mL/min/1.73
97,005
(CKD-EPI) m2
Uric acid 3.4-7.0 mg/dL
CRP 11,24 ↑ 3,96 ↑ < 0,3
 Chemistry 07/09 Reference
Lipid Profile
Total Cholesterol 147 <200 mg/dL
Trigliserida 194 <150 mg/dL
HDL Cholesterol 36 >50 mg/dL
LDL Cholesterol 84 <100 mg/dL
 Blood 14/09 19/09 20/9 Reference
Chemistry
FBG 181 (08:23) ↑
Glukosa 285 (11:02) ↑ 227 (07:19) ↑ < 200 mg/dL
(POCT)
RBS 287 (11:47) ↑ 60-100 mg/dL
Hb-A1c 12,40 < 5,7 %
Equivalent to 309,2
 SE 14/9 Reference
(11:47)
136 – 145
Na 133 mmol/L
136
3.5 – 5.0
K 4,57 mmol/L
98 – 106
Cl 101 mmol/L

Osmolality Serum = 2 [Na]+glucose (mg/dL)/18+BUN (mg/dL)//2.8

= 2 (136) + 287 /18 + (53.1/2.14)/ 2.8
= 272 + 15.9 + 24.81/ 2.8
= 287.9 + 8.86
= 296.76
 Immunoserology 14/9 Reference range
Total Antibody SARS-CoV-2 Non-reactive COI <1.0: Non-
COI: 0.105 reactive
COI ≥1.0: Reactive

Procalcitonin 0,12 < 0,5 ng/mL Low

risk for severe
sepsis or septic
shock
> 2 ng/mL High risk
for severe sepsis or
septic shock
USG Doppler left extremity sinistra
• Conclusion:
-Match with DVT description along the left superficial femoral vein
-Left lower extremity subcutaneous edema
CXR
• Conclusion:
-Cardiomegaly
-Infiltrate
Therapy
• O2 NC 2-4 lpm Peroral:
• Inf NS 0.9 % 500 ml/24h • Atorvastatin 0-0-20mg
• DM diet 1800 kcal/24 hours • Amlodipin 0-10-0 mg
• Inj Levofloxacin 1 x 750 mg • Paracetamol 3 x 500 mg
• Inj vit. C 1 x 500 mg • Warfarin 1 x 6 mg
 Data Interpretations
• Laboratory results showed : leukocytosis, neutrophilia,
increased of d-dimer, ureum, CRP, triglyceride, FBG,
RBG, FBG, and HbA1C
• USG doppler showed DVT along the left superficial
femoral vein and left lower extremity subcutaneous
edema
DATA INTERPRETATION

History taking, physical examination and other

examination showed
1. DVT dt. long bedridden dd/ susp. DM type 2
2. DM type 2 with complication susp. DKA

20
 DATA INTERPRETATION

Suggestion:
• Performing: BGA, keton urine, ketone serum, Bil.
T/D/I, UL
• Monitoring: D-dimer, USG dopller, FBG, RBG,
HbA1C, Osm

21
DISCUSSION

1 • Establishment of
the diagnosis

2
22
 PCCL PL IDx PDx

DVT DVT dt. P. Mo:

1. Female/63 y.o.
1. long bedridden -D-dimer
Laboratory
2. Susp. DM type 2 -USG doppler
D-dimer ↑
FBG ↑, RBG ↑
HbA1C ↑

Anamnesa:
-Left leg edema, warm,
redness & pain
tenderness
-History of long
bedridden
-History of DM + HT
 PCCL PL IDx PDx

1. Female/63 y.o.
Physical examination:
Homans sign,
edema -/+, warm +,
hyperemia
USG dopller: DVT &
left lower extremity
subcutaneous
edema
 PCCL PL IDx PDx

Hyperglycemic Type II DM with Pdx :

2. Female/63 y.o.
crisis complication susp. BGA
Laboratory
DKA Keton urine
FBG ↑, RBG ↑
Ketone serum
HbA1C ↑
Osm ↑
P. Mo:
Anamnesa: -FBG
-History of -RBG
uncontrolled DM -HbA1C
-Osm
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M,
Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS. The third
international consensus definitions for sepsis and septic shock (Sepsis-3). Jama.
2016 Feb 23;315(8):801-10.
SOFA Score 2
 PCCL PL IDx PDx

Susp. Susp. Pneumonia dt. Pdx :

3. Female/ 63 y.o.
Pneumonia 1. susp. bacterial -RT-PCR
Laboratory
infection -Sputum culture
Leukocytosis,
2. Susp. COVID-19
neutrophilia
P. Mo:
NLR ↑, CRP ↑
Abs. lymphocyte N -CBC
Procalcitonin N -CRP
SOFA Score 2 -HbA1C
ECLIA non-reactive -Osm
 PCCL PL IDx PDx

3. Female/ 63 y.o.
Anamnesis:
-Cough, fever
-History of
uncontrolled DM

Physical
examination:
 PCCL PL IDx PDx

Susp. sepsis Susp. sepsis dt. Pdx :

4. Female/ 63 y.o.
1. DVT -Bil. T/D/I
Laboratory
2. Susp.no. 3 -Sputum culture
Leukocytosis,
(pneumonia) -Blood culture
neutrophilia
-RT-PCR
CRP ↑
Procalcitonin N
SOFA Score 2 P. Mo:
-CBC
Anamnesa: -CRP
-Left leg swelling -Procalcitonin
-History of -SOFA Score
uncontrolled DM
 PCCL PL IDx PDx

Susp. sepsis Susp. sepsis dt. Pdx :

4. Female/ 63 y.o.
1. DVT -Bil. T/D/I
Laboratory
2. Susp.no. 3 -Sputum culture
Anamnesa: (pneumonia) -Blood culture
-Left leg swelling -RT-PCR
-History of
uncontrolled DM P. Mo:
-CBC
-CRP
-Procalcitonin
-SOFA Score