University of Puerto Rico

Medical Sciences Campus

School of Medicine
Department of Medicine

CASE PRESENTATION
Student's Name:

Raymond Rivera Vergara

Patient's Initials:

DMU

Student Number:

801-07-7280

Date of Encounter:

JAN 4, 2015

_________________________________________________________________________________
Chief Complaint:

Son report generalized weakness with left hand swelling at time for visit at nursing home.

History of Present Illness:

MLM is a 94 y/o male patient with history of Benign essential hypertension, Hyperlipidemia, Hypertrophy of
Prostate with Urinary obstruction, Cardiac Pacemaker in Situ, dementia, compression fracture, dysphagia who
was brought to emergency room of veteran due to a left arm swelling, redness and pain for the past 3 days. The
patient is a nursing home resident and his son noticed this findings 3 days ago prior admission. Nursing home
staff denied fever, cough, respiratory distress, nausea, vomits or diarrhea. The patient does complain of left arm
pain. He suffered a fall last Jun-July with right hip fracture that had no surgical management and the patient has
been bedridden ever since. Since then, son report patient to be more disoriented and tired. A left arm venous
doppler was done which showed that there is a left axillary vein DVT, that is partially occlusive. The patient was
started on anticoagulation.

Case Presentation - Page 2

Allergies:

NKDA

Childhood illnesses:

negative for Measles, Mups and chickenpox

Adult medical history:

Benign essential hypertension, Hyperlipidemia, Hypertrophy (Benign) of Prostate with Urinary obstruc
Cardiac Pacemaker in Situ, dementia, compression fracture, dysphagia

Medications (include doses): 1) Alendronate 70mg tab 1 tablet po weekly, 14) Metoprolol succinate 25mg 1 tablet po daily
2) Aloe vesta 2-n-1 perineal skin cleanser
15) Tamsulosin hcl 0.4mg cp 1 po daily
3) Atorvastatin calcium 80mg tab 40mg 0.5 tablet po at bedtime 16) Tramadol hcl 50m
4) Buspirone hcl 5mg tab 2.5mg 0.5 tablet po bid
5) Carboxymethylcellulose na 1% oph gel 1 drop ou bid
6) Cyanocobalamin 1000mcg tab 1 tablet po am
7) Docusate na 50mg/sennosides 8.6mg tab 2 tablets po at bedtime
8) Enoxaparin 40mg/0.4ml inj 40 milligrams (0.4 milliliters) sc daily
9) Finasteride 5mg tab 1 tablet po daily
10) Furosemide 40mg tab 10mg 0.5 tablet po am
11) Latanoprost 0.005% oph soln 1 drop ou at bedtime
12) Levobunolol hcl 0.5% oph soln 1 drop ou q12h
13) Megestrol acetate 200mg/5ml oral susp 2 teaspoonfuls po bid

Surgical history:
May 17, 2013: Phacoemulsification with intraocular lens implant left eye.
November 07, 2007: New permanent pacemaker

Family history:
Older son 62: Diabetes, and hypertension
Younger son 56: Diabetes and hypertension
Unknown for parents

Social history:
Son report that he smoked around 40 years ago. Do not recall details

Review of systems:
Yes

No

SYSTEM

General:
Recent weight loss
Recent weight gain
Weakness
Fatigue
Fever
Chills

Skin:
Rashes
Lumps
Sores
Itching
Dryness

Yes

No

SYSTEM
Changes in skin color
Changes in hair
Changes in nails
Changes in size or color of moles

Head, Eyes, Ears, Nose & Throat

Headache
Dizziness
Lightheadedness
Loss of vision
Wears glasses or contact lenses
Eye pain
Redness of the eyes
Excessive tearing

Case Presentation - Page 3

Yes

No

SYSTEM

Yes

No

SYSTEM

Head, Eyes, Ears, Nose & Throat

Cardiovascular

Blurred vision

Paroxysmal nocturnal dyspnea

Double vision

Edema

Spots, flecks, flashing lights

Gastrointestinal

Loss of hearing

Trouble swallowing

Tinnitus

Heartburn

Vertigo

Loss of appetite

Earache

Nausea and/or vomiting

Ear discharge

Change in bowel habits

Frequent ear infections

Change in stool color

Frequent colds

Change in stool consistency

Nasal stuffiness

Pain with defecation

Nasal discharge

Rectal bleeding

Nosebleeds

Tarry black stools

Sinus pain

Hemorrhoids

Neck

Constipation

Swollen glands or lumps

Diarrhea

Goiter

Abdominal pain

Pain

Excessive belching

Stiffness

Excessive flatulence

Breasts

Jaundice

Lumps

Peripheral Vacular

Pain

Intermittent claudication

Discomfort

Leg cramps

Nipple discharge

Varicose veins

Respiratory

Ulcers

Cough

Past clots in veins

Sputum

Swelling of calves, legs or feet

Hemoptysis

Color change in fingertips or toes when cold

Dyspnea

Urinary

Wheezing

Increased frequency

Pleurisy

Nocturia

Cardiovascular

Urgency

History of heart murmurs

Burning or pain during urination

Chest pain or discomfort

Frequent urinary infections

Palpitations

Flank pain

Dyspnea on exertion

History of kidney stones

Orthopnea

Hematuria

Case Presentation - Page 4

Yes

No

SYSTEM

Yes

No

SYSTEM

Urinary (Male)

Neurologic

Reduced caliber or force of urinary stream

Changes in speech

Hesitancy

Changes in orientation

Dribbling

Frequent headaches

Genital (Male)

Dizziness

Hernias

Fainting or blackouts

Discharge from penis

Weakness

Sores or ulcers

Paralysis

Testicular pain

Numbness or loss of sensation

Testicular masses

Tingling sensation

Scrotal swelling

Tremors

History of sexually transmitted disease

Involuntary movements

Genital (Female)

Seizures

Irregular menses

Hematologic

Prolonged menses

History of anemia

Excessive bleeding

Easy bruising

Bleeding between periods

Excessive bleeding

Dysmenorrhea

Past transfusions

Menopause

Endocrine

Menopausal symptoms ("hot flushes")

Heat or cold intolerance

Postmenopausal bleeding

Excessive sweating

Vaginal discharge

Excessive sweat or hunger

Vaginal itching

Polyuria

Sores, ulcers or lumps

Changes in shoe or glove size

History of sexually transmitted diseases

Musculoskeletal
Muscle pain
Joint pain
Backache
Swelling of the joints
Stiffness of the joints
Muscular weakness
Limitation of motion
History of fractures or trauma

Psychiatric
Nervousness
Anxiety
Depressed mood

Health Maintenance:
Vaccinations
Hepatitis B

Last Dose
unknown

Influenza

November 04, 2015

Measles-Mumps-Rubella

unknown

Pneumococcal

May 04, 2015

Tetanus toxoid

unknown

Varicella

not done

Case Presentation - Page 5

Health Maintenance:
Screening

Last Performed

Bone densitometry

Screening

Last Performed

Lipid profile

Not done

Colonoscopy

unknown

Mammography

N/A

Diabetes screening

already +

Pap smear

N/A

Physical Exam:
Vital signs:

Temperature
Weight

Normal

Abnormal

98.2F
139

Heart rate
Height

65
5.5 ft

Respirations

Blood pressure

17

BMI

SYSTEM
General: Alert, awake, and oriented. Appropriate grooming
and hygiene. No acute distress.
Skin: Moist skin. No ulcers, rashes, or lumps. Normal hair
and nails. No jaundice.
HEENT: Normocephalic. Sclearea white. Normal visual
acuity. Pupils equally reactive to light. Normal eye fundi.
Normal ear canal. Weber midlince. Rinne AC>BC.
Normal nasal mucosa. No sinus tenderness. Moist oral
muscosa. Good dentition. No erythema or exudates.

Pain

110/60
0

ABNORMAL FINDINGS

Oriented only to person.

Watery ulcers, rashes mainly in upper

extremities extremities.
Poor visual acuity.

Neck: No palpable masses or lumps. No goiter. Neck supple.

No palpable lymph nodes. No jugular venous distention. No
carotid bruits.
Thorax and Lungs: No tenderness to palpation of spinal
processes. Normal lung expansion. Normal tactile fremitus
No egophony or whispered pectoriloquy. Lungs clear to
auscultation with no ronchi, crackles or wheezing.
Breasts and Axillae: No lumps or masses. No discharge.
Heart: Non-displaced apex. Regular rhythm. Normal S1
and S2. No S3 or S4. No audible murmurs. No clicks, rubs
or other sounds.

Pace maker.

Abdomen: Normal bowel sounds. No abdominal bruits

No tenderness to palpation. No masses. Normal liver span.
No splenomegaly. No ascites.
Extremities: No ulcers or discoloration. No edema.
Peripheral pulses +2 throughout. No deformities of the
joints. Normal range of motion. Normal muscle bulk and
tone.

Watery ulcers in upper extremities.

Case Presentation - Page 6

Normal

Abnormal

SYSTEM

ABNORMAL FINDINGS

Neurologic:
Mental status: Alert, awake, and oriented. Appropriate
speech. Normal mentation, insight, judgement, and memory.
Cranial nerves: Normal sense of smell. Normal visual
acuity, visual fields, and ocular fundi. Normal pupillary
reaction. Normal extraocular movements. Normal corneal
reflex, facial sensation, and jaw movements. Normal facial
movements. Normal hearing. Weber midline. Rinne AC>
BC. Normal swallowing and rise of the palate. Intact gag
reflex. Normal voice and speech. Normal shoulder and
neck movements. Normal tongue symmetry and position
Motor system: Normal muscle tone and bulk. Strength 5/5 in
all muscle groups. Point-to-point movements and rapid
alternating movements intact. Normal gait.
Sensory system: Normal sensation to pain, temperature,
light touch, vibration,and point discrimination.
Reflexes: Normal biceps, triceps, brachioradialis, patellar,
and Achilles deep tendon reflexes.

Motor evaluation for lower limb was

ommitted due to chronic back pain.
Patient refuses motor system
examination.

Laboratory Findings:

11.9
11.9

142

99

14.9

219
38.6

130
3.1

17.5

0.73

Segmented neutrophils

74.8%

Aspartate dehydrogenase (AST)

N/A

Lymphocytes

19.8%

Alanine dehydrogenase (ALT)

N/A

Eosinophils

0.1%

Alkaline phosphatase

N/A

Monocytes

5.8%

Bilirubin, total

N/A

Mean corpuscular volume

86.4fL

Bilirubin, direct

N/A

Mean corpuscular hemoglobin

32.9pg

Magnesium

N/A

Other relevant laboratories:

Imaging studies:

Electrocardiogram:

99% saturation
INR 1.33
PROTHROMBIN TIME 15.8 H Secs. 11.8 - 15.0
PARTIAL THROMBOPLASTIN TIME 32.6 Secs.

[672]
22.4 - 38.3

[672]

VENOUS ULTRASOUND LEFT UPPER EXTREMITY:

Left upper extremity: Incomplete compression and partial flow in the left axillary vein in
keeping with nonocclusive thrombus though the more peripheral aspect of the axillary vein
thrombus may not be fully assessed on the submitted compression and color/spectral
- Ventricular
rate: Spectral
74 bpm waveform analysis: Augmentation deferred. No significant loss
Doppler
imaging.
-ofQTc:
492
ms
respiratory variability at the brachial veins. Venous structures identified and cleared:
- Ventricular
Pacemaker
Internal
jugular
vein, subclavian vein, brachial veins, radial veins, ulnar veins.
Subcutaneous edema is seen in the left upper extremity. Superficial upper extremity veins:

Imaging Studies

VENOUS ULTRASOUND LEFT UPPER EXTREMITY:

Left upper extremity: Incomplete compression and partial flow in the left axillary vein in
keeping with nonocclusive thrombus though the more peripheral aspect of the axillary vein
thrombus may not be fully assessed on the submitted compression and color/spectral
Doppler imaging. Spectral waveform analysis: Augmentation deferred. No significant loss
of respiratory variability at the brachial veins. Venous structures identified and cleared:
Internal jugular vein, subclavian vein, brachial veins, radial veins, ulnar veins.
Subcutaneous edema is seen in the left upper extremity. Superficial upper extremity veins:
Cephalic and basilic veins are unremarkable.
Deep venous thrombus involving the left axillary vein, partially occlusive were assessed.

Case Presentation - Page 7

Assessment:

Patient of 94y/o with history of Hypertension , old Cerebrovascular accident, dementia, BPH that was brought
to VAER due to presenting left arm with edema and hyperemia since 3 day of evolution. History was taken
from son.
At evaluation patient disoriented in time and place but oriented in person, without acute cardiopulmonary
distress, on swelling of left arm with sever non-pitting edema, and hyperemia. On CBC it shows mild
leukocitosis. This could be due to inflammatory process or normal levels for this older patient.
Most likely diagnosis, is a DVT of the left arm base on doppler, clinical presentation and limited of movement
do to pelvic tracture. Treatment will be Will admit patient due to DVT with enoxaparin, no need for IV
antibiotics due to no infections process. Will provide analgesia also. Talk to son and sign DNR due to both
sons agree in the past that patient will be DNR. Family members oriented about condition and plan and they
understand and agree. Information of possible option with anticoagulants at home was provided. Family
members understands contraindication and still deciding weatherer or not continue anticoagulation therapy
at home.
Differential diagnosis include Cellulitis, patient present with watery skin and mild leukocitosis which could be
sings of cellulites. However, imaging studies confirm the presence of incomplete compression and partial
flow in the left axillary vein with nonocclusive thrombus. And watery skin could be do to skin fragility due to
patients age. Superficial Thrombophlebitis could be another differential diagnosis, but occlusion of left axillary
vein, and not in a superficial vein, is present. Trousseaus syndrome, is highly unlikely due to the presence of
single DVT and not in multiple extremities. Nerveless, patient age is a risk factor for any cancer, not only
pancreatic types.
Currently patient is on a INR of 1.33, PT of 15.8 S , PTT: 32.6 S. INR and PT are slight elevated. Both are
used to measure Activation of extrinsic pathway. LMWH does not prolong aPTT; minimal prolongation of ACT
may be observed. Routine coagulation monitoring is not required for this patient. However, during treatment
the peak anti-Xa level (not to exceed 1.5 Units/ml) is determined 4 hours after the 3rd dose. The trough level
(>0.5 Units/ml) is determined before the 4th dose. The test is performed in the UMass-Memorial laboratory.

Plan:

Take vitals every 8 hours, limit activity only to bed rest, have the nursing personel to visit patient every 8
hours. Give a low sodium diet. Measure Input and output of liquid daily.

References:

STUDENT SIGNATURE: