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NITHIYA, 35, Indian Female at 12U

History Taking
Presenting Symptom Abdominal Pain

HOPI Abdominal pain


 Epigastric
 3/7 days
 Tight in nature
 Associated with nausea, bloating, worsening shortness of breath due
to pain
 Orthopnea
 Loose stool 1/day for 3/7
 No vomiting
 Attributed it to poor dietary habit, skip meals
 SOB is overall better than 3 weeks ago
 No radiation
 Pain is persistent
 Score=?
 Exacerbating factor?
 Left leg swelling for 1/12
 Back pain 1/12

Otherwise
 P/U B/O normal
 NO haematemesis
 7kg weight loss due to recent lifestyle changes

Rule out SLE Noticed frothy urine lately


No hair loss
No oral ulcer
No rashes
No photosensitivity
No joint pain

Ruling out DDx of Abdominal Pancreatitis


Pain  Nausea
 Vomiting
 Pain radiating to the back
Gallbladder disease
 Jaundice
 Referred shoulder pain
 Pale stool
 Tea-coloured urine
Pulmonary Embolism
 Haemoptysis
 Shortness of breath
 Sudden onset
Pneumonia
 Fever
 Cough
 Aneroxia
Renal causes of leg swelling
 Nephritic/Nephrotic
 Ask about recent URTI
DVT
 Painful leg swelling
Mesenteric Ischaemia
 Secondary to Clotting abnormalities
APLS
 Family Hx
 Hx of DVT
 Current Dx of PE
Costochondritis
 Pleuritic chest pain
 Viral causes
 Fever,o

Past Medical History Deep Vein Thrombosis


 Diagnosed 7 years ago
 Unprovoked
 On Warfarin for 2 years before stopping; ordered by doctor
 Follow-up
 Complications (recurrent DVT)
Pulmonary Embolism
 Diagnosed 3 weeks ago at UMSC
 Had symptoms of cough and fever since February when she came back
from Kashmir (4 hour flight)
 Took typhoid vaccine
 Took Abx and symptomatic relief meds
 February
 Xray done = clear
 TB screen= negative
 Denies sick contact
 3 weeks prior to recent admission, sudden chest pain associated with
difficulty breathing & ambulating
 Denied admission by A&E department twice
 Went to UMSC, did CT Angio confirm Pulmonary Embolism
 Put on Rivaroxaban 15mg BD

Others:
Details on follow/up
Admission
Previous CT/XRay /Blood Result
Connective Tissue Disease screening
Compliance to drugs
Extent of functional disabilities, effort tolerance
Complications; Heart failure
Gynaecological Hx Menarche at 11
Period is 4-5 days
Cycle?
Experiencing heavy menses and passing clots during the LMP
Pregnancy?
OCO/HRT
Past Surgical Hx
Drugs and Allergy Currently on
 Rivaroxaban 15mg BD
 Omeprazole
 Paracetamol for pain
 Ayurvedic supplements
Family Dad
 Died at 45 due to MI
 Mentioned about uncle dying around the same age, unsure
Mother,2 other sisters are well
Youngest sister has SLE, Lupus Nephritis, APLS, on lifelong warfarin under Prof
Sargunan

NO hx of malignancy
Chronic lung disease
Bleeding/Clotting disorder
Chronic disease (T2DM, Htn, Hypercholesterolaemia)
Social Hx Single
Non-smoker
Occasional alcohol drinker
Sexual activity?
Lives with mom and SLE sister
Private tutor
 Works 2-6 hours a day
 3 sessions of tutoring per day
 Travels around Selangor to teach
 Earns? Is she the sole breadwinner?
Lives at Kepong
Diet & Lifestyle Overweight
Started to change lifestyle 2 years ago
Currently active in yoga
Influenced by yogi to lose weight as to achieve certain yoga pose
Been skipping meals
Lost 7kgs in a year

Issues & Concerns Issues


 Blood clots during menses
 Activity limitation due to SOB
 Abdominal pain

Physical Examination Findings (on admission)

During clerking, couldn’t complete examination due to patient’s condition


On auscultation, Reduced breath sound bilaterally
General 135/85mmHg (Hypertensive)
Heart Rate 92bpm (Normal)
Pain scale 5/20
Spo2 93%
Crt <2secs

JVP raised
Bilateral pedal oedema up to thigh
Abdomen
Respiratory System Reduced breath sound bilaterally
Cardio S1s2nm
DVT See template attached below
Investigations
Blood Ix
FBC RBC- (Anaemia)
WBC- Respiratory Infection/AGE (Leukocytosis)
Plt- (Thrombocytopenia)

Coagulation Profile PT (prolonged)


APTT (prolonged)
Urine UFEME Protein(4+)
RFT Renal function TRO renal causes of frothy urine
LFT TRO Gallbladder/Liver causes of abdominal pain
Albumin

Amylase TRO Acute Pancreatitis

Immunonology ANA 1:180,Ds-DNA (-ve), IgG, IgM, anti-c3d(++), Lupus Anticoagulant(+ve), cardiolipin
Ab (pending), DAT (+ve)
ENA screening Also Known As Antibodies to Saline-extracted Antigens Anti-RNP Anti-
Ribonucleoprotein Anti-U(1)RNP Anti-SmRNP Anti-SSA SSA (Ro) Anti-Sjögren
Syndrome A Anti-SSB SSB (La) Anti-Sjögren Syndrome B Anti-Sm (Sm) Smith Antibody
Scl-70 Anti-Topoisomerase Scleroderma Antibodies Anti-Jo-1 Antihistidyl Transfer RNA
Synthase Antibodies

When to order:
When ANA (+ve)
Serum Beta-2- To monitor multiple myeloma or lymphoma
microglobulin Query on why it was ordered for this patient
C3. C4 Normal
Imaging
Chest Xray TRO infective causes of SOB/Cardiomegaly(heart failure)
Erect abdominal Xray TRO perforated abdomen (Normal)
u/s Abdomen To exclude gall bladder stones/ choledocholithiasis
CT TAP
CT Angio Diagnostic Ix for Pulmonary Embolism
CT Mesenteric Impressions
1. No evidence of mesenteric thrombosis or bowel ischaemia
2. Liver hemangiomas present
3. Uterine fibroid
Doppler U/S TRO DVT
Echocardiography To visualise Cardiomegaly and Pulmonary vessels
ABG

Health Issues to Manage


Abdominal pain
Shortness of breath secondary to pulmonary embolism
To address issues of compliance
To address lifestyle

Management (Acute)
Pain
 Tramadol (why Tramadol) – pain score was 5, aim to taper to below 5.
IF suspect gastritis
 Ranitidine
 IV Pantoprazole
 Syrup MMT
 Tab Buscopan

Supplemental Oxygen
Keep NPO

 Remove the inferior vena cava filter when the patient becomes eligible for anticoagulation
treatment, at the earliest possible opportunity
Management (Long term)
Address issue of compliance and risk assessment, complications of anticoagulation therapy
Refer dietician for weight management
Physiotherapist/sports medicine for activities that can be done to reduce weight effectively
Refer to Respiratory physician/ Rheumatology

Discussion
Topics/
What is 1) An autoimmune, hypercoagulable state caused by antiphospholipid antibodies.
APLS(Anti 2) Associated with SLE (20-3-% of APLS cases)
Phospholipid 3) Ab (Anticardiolipin Ab + Lupus Anticoagulant)
Syndrome)? 4) Vauses CLOT; Coagulpathy, Livedo Reticularis, Obs problem (miscarriage),
Thrombocytopenia
*Taken from Oxford Med
Pathophysiolog Virchow’s Triad:
y of DVT/PE 1. Hypercoagulability
2. Endothelial injury
3. Vascular stasis
Do you screen
this person who
SLE?

Diagnostic criteria:
 4 or more of the criteria (1 clinical and 1 lab)
OR
 Biopsy-proven lupus nephritis with +ve ANA or anti-DNA
Pathophysiolog
y of DVT

CTEPH