80 year old female with swelling of left lower limb

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Unit II admission on 21/02/2021 
DR. JAYANTH ( INTERN) 
DR. AMULYA ( INTERN) 
DR. SURYA PRADEEP ( INTERN) 
DR. ASHA KIRAN ( INTERN)
DR. YAMINI ( INTERN) 
DR. VAMSHI ( INTERN)
DR. ISMAIL  (INTERN)
DR. PRADEEP ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR) 
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI

Here is a case i have seen: 
80 year old female who is a homemaker came with the c/o-
Swelling of left lower limb since 10days associated with pain. 
H/o poison intake 20days back->OP poisoning which was treated outside, from then patient is on medication-> T. QUITIPINE 5R 500 OD, 
T. RISPERIDONE 2mg OD, T. DIMEFAS ODS 5mg OD. 
Past history- 
K/c/o HTN since 5years on T
No similar complains in the past. 
Tubectomy done
No h/o any prolonged immobilisation. 

VITALS-
PR-80bpm
BP-130/80mmhg
RR-17cpm
SpO2-98% at RA
RS- BAE present
P/A-Soft and NT
CVS-S1S2 present
CNS-NFD

INVESTIGATION-
APTT-32sec
PT-16sec
INR-1.11
PROVISIONAL DIAGNOSIS-DVT OF LEFT LOWER LIMB. 
TREATMENT on day of admission-16/03/2021
1.INJ. CLEXANE 60mg SC OD. 
2.Monitor vitals. 
3. GRBS 12th hourly. 

TREATMENT ON DAY 1 -17/03/2021
S-
Subjectively patient is feeling better. 
C/o unilateral lower limb swelling of left leg. 
No skin induration. 
No change in appearance, colour. 
O-
Patient is c/c.
Afebrile
BP-140/80mmhg 
PR-78bpm normal volume and regular rhythm
CVS-S1 S2 present
RS-BAE present
PA-soft and NT
CNS-NFD
A-
LEFT LOWER LIMB DVT
P-
1.Inj.  ENOXAPARIN 60mg SC OD. 
2.T. ATEN 50mg PO OD. 
3. T. QUITIPINE 5R500 PO OD. 
4. T. RISPERIDONE 2mg PO OD. 
5. T. DIMEFAS ODS 5mg PO OD. 

TREATMENT ON DAY 2-18/03/2021
S-
Subjectively patient is feeling better. 
No skin induration. 
No change in appearance, colour. 
O-
Patient is c/c.
Afebrile
BP-130/80mmhg 
PR-78bpm normal volume and regular rhythm
CVS-S1 S2 present
RS-BAE present
PA-soft and NT
CNS-NFD
A-
LEFT LOWER LIMB DVT. 
OBG referral was taken i/v/o any mass per vaginum-
P-
1.Inj.  ENOXAPARIN 60mg SC OD. 
2.T. ATEN 50mg PO OD. 
3. T. QUITIPINE 5R500 PO OD. 
4. T. RISPERIDONE 2mg PO OD. 
5. T. DIMEFAS ODS 5mg PO OD. 

INVESTIGATIONS-
PT-18sec APTT-36sec  INR-1.33
TREATMENT ON DAY 3-19/03/2021
S-
Subjectively patient is feeling better. 
No skin induration. 
No change in appearance, colour. 
O-
Patient is c/c.
Afebrile
BP-110/80mmhg 
PR-88bpm normal volume and regular rhythm
CVS-S1 S2 present
RS-BAE present
PA-soft and NT
CNS-NFD
A-
LEFT LOWER LIMB DVT
P-
1.Inj.  ENOXAPARIN 60mg SC OD. 
2.T. ACITROM 2mg PO OD. 
3. T. QUITIPINE 5R500 PO OD. 
4. T. RISPERIDONE 2mg PO OD. 
5. T. ATEN 50mg PO OD. 

TREATMENT ON DAY 4-20/03/2021
S-
Subjectively patient is feeling better. 
No skin induration. 
No change in appearance, colour. 
O-
Patient is c/c.
Afebrile
BP-110/80mmhg 
PR-80bpm normal volume and regular rhythm
CVS-S1 S2 present
RS-BAE present
PA-soft and NT
CNS-NFD
A-
LEFT LOWER LIMB DVT
P-
1.Inj.  ENOXAPARIN 60mg SC OD. 
2.T. ACITROM 2mg PO OD. 
3. T. QUITIPINE 5R500 PO OD. 
4. T. RISPERIDONE 2mg PO OD. 
5. T. ATEN 50mg PO OD. 

TREATMENT ON DAY 5-21/03/2021
S-
Subjectively patient is feeling better. 
No skin induration. 
No change in appearance, colour. 
O-
Patient is c/c.
Afebrile
BP-110/80mmhg 
PR-80bpm normal volume and regular rhythm
CVS-S1 S2 present
RS-BAE present
PA-soft and NT
CNS-NFD
A-
LEFT LOWER LIMB DVT
P-
1.T. ACITROM 2mg PO OD. 
2. T. QUITIPINE 5R500 PO OD. 
3. T. RISPERIDONE 2mg PO OD. 
4. T. ATEN 50mg PO OD. 
INVESTIGATIONS-
PT- 16sec APTT- 31sec INR-1.11



TREATMENT ON DAY 6-22/03/2021
S-
Subjectively patient is feeling better. 
No skin induration. 
No change in appearance, colour. 
O-
Patient is c/c.
Afebrile
BP-100/60mmhg 
PR-76bpm normal volume and regular rhythm
CVS-S1 S2 present
RS-BAE present
PA-soft and NT
CNS-NFD
A-
LEFT LOWER LIMB DVT
P-
1.T. ACITROM 2mg PO OD. 
2. T. QUITIPINE 5R500 PO OD. 
3. T. RISPERIDONE 2mg PO OD. 
4. T. ATEN 50mg PO OD. 

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