CASE PRESENTATION Dr Sara Ahmed

PG Resident

Medical Unit 1,BBH

PERSONAL PROFILE

Mr. Shaukat

33yrs/Male

Watchman at school

Resident of Rawalakot AJK

Presented on 31-05-2015 through emergency

PRESENTING COMPLAINTS

Coughing up of blood – 3 days

Chest pain – 1 day

HISTORY OF PRESENT ILLNESS Patient was alright 5 months back when in

January 2015, he developed swelling of right leg associated with pain that increased progressively

Advised Doppler USG right leg at a private hospital in Rawalpindi that revealed sluggish flow in right popliteal vein,normal in femoral vein and evidence of thrombosis in popliteal vein.

No H/O immobilization, past surgery and any evidence of previous DVT

CONTINUED..

No H/O chestpain, hemoptysis and SOB at that time

Started Warfarin 7.5mg after overlapping with enoxaparin for 3 days

He was advised to continue Warfarin 7.5 mg daily at home for six months and report back fortnightly with INR.

With this treatment his swelling and pain right leg started to subside gradually however no follow-up doppler ultrasound to look for recanalization of popliteal vein was done.

He did not turn up for follow-up to the private hospital but got his INR done for a few times.

His INR values while being on Warfarin were:

(desirable INR=2-3)

14-2-2015 - 2.5 16-3-2015 - 2.1 16-4-2015 - 2.3 16-5-2015 - 1.0 28-5-2015 - 1.2

Patient was strictly compliant with treatment till time of presentation to BBH Emergency

No H/O vomiting after taking Warfarin or any other symptoms suggestive of malabsorption

No H/O change of brand or dose of drug.

No H/O use of any other drug alongwith Warfarin except acetaminophen for pain relief for first few days

May 2015 (1 month prior to presentation to ER)

Cough – 1 month

Non productive More at night Aggravates on lying down Not associated with fever , SOB , orthopnea ,

PND, and chest pain

Coughing up of Blood – 3 days 3-5 episodes daily 1 cupful in amount/episode Bright red in color with no clot No H/O bleeding from any other orifice or easy bruisibility.

Chest pain – 1 day

Sudden onset Central Continuous Dull, poorly localized Severe Radiating to back Aggravated by cough Relieved with analgesics No H/O SOB at presentation

No h/o omission or change of drug i.e. Warfarin

GENERAL INQUIRY

Sleep , appetite and bowel habits are normal.

No h/o weight loss

SYSTEMIC INQUIRY

Systemic inquiry regarding GIT, CNS and CVS revealed no abnormality

No H/O joint pains, hair loss ,oral ulcers ,rash or any symptom suggestive of autoimmune disorder.

PAST HISTORY

H/O burn of right hand in childhood that led to amputation of fingers of right hand.

FAMILY HISTORY

Not significant

No H/O similar illness in family.

PERSONAL HISTORY

Smoker for 20 years - 40 cigarettes per day

No H/O any other drug addiction

DRUG HISTORY

Tab Warfarin 7.5mg Once daily for 4 months

Acetaminophen occasionally for pain relief

EXAMINATION

GENERAL PHYSICAL EXAMINATION

A young obese man with plethoric face sitting on bed with IV cannula on Left hand

Pallor -ve Weight 98kg

Jaundice- ve Height 5’2 Cyanosis- ve BP 100/60 mmHg Clubbing- ve R/R:16/min Koilonychia-ve Temp 98.6 F

LN- not palpable Pulse 104 / min Thyroid-not Enlarged

Examination of both legs did not reveal any signs of DVT at time of presentation to BBH emergency.

SYSTEMIC EXAMINATION

Respiratory system

Inspection and Palpation unremarkable.

Percussion : Dull note B/L at bases posteriorly.

Auscultation: Reduced intensity of breath sounds B/L at bases posteriorly.

SYSTEMIC EXAMINATION

GIT : Unremarkable

CVS : Unremarkable

CNS : Unremarkable

FUNDOSCOPY

Hyperemic disc margins

DIFFERENTIAL DIAGNOSIS

Lower respiratory tract infection

Pulmonary Embolism despite taking Warfarin

Warfarin toxicity leading to hemoptysis

INVESTIGATIONS

INR

Patient was on Warfarin and INR values were :

Desirable INR – 2.5 (2-3)

Date Patient’s result

14-2-2015 2.5

16-3-2015 2.1

16-4-2015 2.3

16-5-2015 1.0

28-5-2015 1.2

31-5-2015 1.2

BLOOD CPTest 1-06-2015

Hb 14.9 g/dl

MCV 99 fl

MCH 30.8 pg

RBC 48,400,00 /cmm

TLC 10,900 /cmm

Neutrophils 76 %

Lymphocytes 21%

Platelets 176,000/cmm

LFTS

Test 1-06-2015

ALT 34 IU/L

AST 36 IU/L

ALP 156 IU/L ( Normal 90-190)

TBIL 1.8 mg/dl

Albumin 3.6 g/dl

RFTS , SERUM ELECTROLYTES

Test 1-06-2015

Urea 36 mg/dl

Creatinine 1.05 mg/dl

Uric Acid 6.5 mg/dl

Na 136 mEq/l

K 4.2 mEq/l

URINE R/E

Parameter Result

Appreance Yellow clear

Sp Gravity 1.010

pH 6.0

Albumin nil

Sugar nil

Ketones nil

Blood nil

RBC nil

Granular casts nil

Pus cells 2-3 / HPF

Hyaline casts nil

Cystals nil

METABOLIC PROFILE

Test Patient’s value Reference values

BSF mg/dl 84 < 90

Cholesterol mg/dl 216 <200

Triglycerides mg/dl 304 Upto 150

LDL mg/dl 88 <130

HDL mg/dl 41 >50

ABGS (1-06-2015)

Parameter Result Reference value

pH 7.408 7.35 – 7.45

PCO2 36.3 32 - 45

PO2 49 83-108

TCO2 24 21-28

HCO3 22.9 22-29

BE -2 -2 to +3

SPO2 % 84.8 95 – 99 %

31-5-2015

Parameter Result Reference value

FDP 800ng/ml < 400ng/ml

ECG

Normal except for Sinus Tachycardia

ECHOCARDIOGRAPHY

Normal sized LV with normal systolic function

EF 60%

No RWMA ,valves anatomy normal

Normal RA / RV

No signs of Pulmonary Hypertension

PAP 15mmHg

No pericardial effusion

CHEST XRAY(PA VIEW)

DOPPLER STUDY OF LEGS (2-06-2015)

Deep veins of both the legs show normal flow and compressibility

No Evidence of thrombosis

ULTRASOUND ABDOMEN

LIVER : Enlarged ,fatty measuring 16.2cm in size.

GB : 1.2cm Calculus noted

Spleen : Normal

Pancreas : Normal

Kidneys : Rt Kidney Normal Left Kidney shows single 8mm Calculus

Prostate : Normal

CTPA CTPA

INITIAL CTPA REPORT

A preliminary report of CTPA was verbally told by the junior doctors of Radiology department that there is no evidence of pulmonary embolism and patient should be managed on lines of respiratory tract infection.

Due to strong clinical suspicion of PE it was requested to review the CTPA by senior radiologist who gave their final report as follows.

FINAL CTPA INTERPRETATION

B/L Pulmonary Embolism of lower subdivision of Rt Interlobar artery and intersegmental branches of lower subdivision of Left Pulmonary artery supplying posterobasal segment of left lower lobe along with three areas of Pulmonary Infarction

Mild left sided pleural effusion

CTPA

CTPA

DIAGNOSIS

Pulmonary Embolism despite Conventional Oral Anticoagulation

HOSPITAL STAY AND MANAGEMENT

Stayed in hospital for 16 days managed with antibiotics for first 5 days and despite hemoptysis Enoxaparin was started on first day due to strong suspicion of PE.

Inj Ceftriaxone 1g I/V B.D

Inj Clarithromycin 500mg I/V B.D

Inj Enoxaparin 80mg S/C B.D

After starting Enoxaparin his chest pain and hemoptysis settled in 3 days

Enoxaparin was continued for 16 days in maximum dose i.e, 80mg s/c twice daily during his stay in hospital.

He was stable at the time of discharge when Enoxaparin was switched to Rivaroxaban 10mg twice daily

AUTOIMMUNE / INFLAMMATORY MARKERS

Test 1-6-2015

ANA -ve

ESR 70

CRP 82.7 +ve

C3 Normal

C4 Normal

Anti Ds DNA -ve

He was planned for further investigations like thrombophilia screen to evaluate the cause of DVT and Pulmonary Embolism but it was not possible because of financial constraints.

FOLLOW UP

Followed up after 1 month and he had no complains of chestpain, hemoptysis , dyspnea or any leg swelling.

THANK YOU