Case presentation

Presented by: Iqra Fareed

Presented to: Dr Rashida Munir

Roll number: 7228

Semester: DPT 9th
 Demographics
Name: Maqsooda Bibi S/O: Mushtaq Ahmad
Age : 45 years
Gender: Female
IP/OP: Op (MedicL-I)
Marital statue: married
Occupation: Housewife
Residency: Green Town, Faisalabad
Handedness: Right
Date of admission: 2-Dec-2021
 Chief complaint
Patient came with complaint of left leg swelling abdominal
pain and breathlessness from past 30 days.
• History of present illness: Before 30 days patient was
apparently developed leg swelling and pain. She was admitted
in private hospital later and also had abdominal pain,dull pain
moreover the right hyochondrium.

• Needs: To relieve pain and swelling of left leg.

• Past medical History: No significant history in this regard.
• Family History: Patient had family history of
HTN(Hypertension)
Living environment:
she is living in clean and hygienic
environment.
Socioeconomic history:
She belongs to Middle class.
Medical Diagnosis: 1-acute cholecystitis
2-symptomatic gallstones
Medication: injection penitrax 4.5 g I/V , toradol I/V,
kinz+maxolon I/V
Needs:
to get rid of pain , fever and be able to effectively breath
and perform ADLS
Symptoms History
Site: Left leg Aggravating
factor:

Onset: Sudden Standing for sometime

Type: Sharp

Relieving factor:

Duration: continuous At rest

Severity: 7/10 on VAS

Vital signs
Temperature: 98˚F
Blood pressure: 130/90mmHg
Heart rate : 76 beats/min
Respiratory rate: 14 b/min
General health status
Level of awareness:Alert
Body type: leanBMI(16.9)

Dyspnea: N/A
Thyroid: normal
Smoker/non-smoker: non-smoker
Chest pain: no
Lymph nodes: Not palpable
Orthopnea: N/A
Palpitations:N/A
Pain/sweat: pain present
Syncope:N/A
Clubbing:N/A
Fatigue: present(general)
Vomiting:present
Sputum color& amount: N/A
Peripheral edema:N/A
Fever:N/A
Jaundice:N/A
Hypertension:N/A
Hemoptysis:N/A
Cyanosis:N/A
Anemia: present
Nausea:N/A
Objective examination
inspection
Shape of chest: normal and symmetrical
Breathing pattern :
Abdomino - Thoracic:
Thoraco-Abdominal: Yes
Position of trachea: central
Inter costal spaces : normal
Apex beat: palpable at 5th inter costal space
Chest wall pain/ tenderness: present
Pulses:
Carotid: palpable
Brachial: palpable
Radial: palpable
Pulse description
Rate : normal
rhythm: regular
Auscultation
Breath sounds
overall lung sounds were dull
Imaging:
ECG: showing DVT.
Diagnotic tests
Blood CP No Cardiac No
Enzyme
Urine RE No HCV No
RFTs No HIV No
LFTs No S. No
Electrolyte
TFTs No S. Calcium No
BSR No S. Creatinine No
BFR No S. Urea No
ECG Yes S. Amylase No
[Link] No S. No
Cholesterol
Prothrombin Time No
Impairments:
• Swelling with pitting edema
• Increased skin temperature and pain
• Calf pain and tenderness

• Activity limitation:
• Difficulty in walking for prolonged time.
• Difficulty in sleeping sometimes due to severity of pain.
• Difficulty is sitting or standing for prolonged time
Participation restriction:

could not perform social responsibilities ( go to work ,

do grocery)

Physiotherapy diagnosis:
Femoral DVT, Discoloration in leg
Management:
Short term goals:
• To decrease pain.
• To prevent morbidity.
• To prevent post phlebitic syndrome.
• To prevent pulmonary embolism

Long term goals:

• To prevent reccurence by leg strengthening
• To regain mobility for prolonged times
• To increase physical functioning.
Plan of care:

Ankle pump exercise 10 rep 3 sets

Use of compression stockings
Elastic compression should be applied beginning with 1 month of
diagnosis of dvt and continue 1 year.