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History Taking
Presenting Symptom Abdominal Pain
Otherwise
P/U B/O normal
NO haematemesis
7kg weight loss due to recent lifestyle changes
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
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)
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
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