A 45-year-old man is evaluated - pacemaker

[ArchivalUser]

A 45-year-old man is evaluated in the emergency department for acute shortness of breath with right-sided chest pain. He also has a dry cough with scanty blood streaking of his phlegm. He is a nonsmoker and has no other past medical illnesses; he has just returned by airplane from Japan.

On physical examination his temperature is 37.4 °C (99.4 °F), blood pressure is 102/76 mm Hg, pulse rate is 98/min, and respiration rate is 32 /min. Breath sounds are marginally decreased on the right side with vocal fremitus. There are no rhonchi. The pulmonary component of the second heart sound is accentuated. He feels soreness in the left calf and has trace left ankle edema. All peripheral pulses are intact.

Compression ultrasonography of the lower extremities is positive for the presence of deep vein thrombosis. A follow-up spiral CT scan of the chest confirms the presence of pulmonary emboli and a small right-sided pleural effusion. The patient is hospitalized and therapy with fractionated heparin and warfarin is started. On day 3, the prothrombin time 14.7 sec; INR is 1.6. Chest radiograph at this time shows a stable right-sided pleural effusion occupying about one fourth of the right hemithorax. Ultrasound guided aspiration of the right pleural effusion is performed.

Laboratory Studies
Cell count

Erythrocyte count 100,000/μL (100 × 109/L); leukocyte count 465/μL (0.465 × 109/L) with 70% neutrophils, 25% lymphocytes, 2% mesothelial, and 3% eosinophils.
Total protein

3.5 mg/dL (35 g/L)
Lactate dehydrogenase

400 U/L
Glucose

75 mg/dL (4.16 mmol/L)
pH

7.45
Gram stain of pleural fluid shows no organisms.

Which of the following is the most appropriate next step in management?

A Discontinue heparin, continue warfarin
B Discontinue warfarin
C Continue heparin and warfarin till INR is therapeutic, and then discontinue heparin
D Discontinue both heparin and warfarin
E Place an inferior vena cava filter

[ArchivalUser]

aaaaa

[ArchivalUser]

C Continue heparin and warfarin till INR is therapeutic, and then discontinue heparin

[ArchivalUser]

.................

[ArchivalUser]

ans with explanation plzzzzz pacemaker

[ArchivalUser]

i think c is right,,,,,,,,,,,,,,,coz stopping heparin isnt the right choice here, and the therapeutic INR hasnt reached yet, so the pt needs both and then once INR is therapeutic than heparin can be stopped and pt maintained on warfarin.....................great darkhorse

[ArchivalUser]

Correct Answer = C)
Key Point
Approximately 80% of effusions associated with pulmonary emboli are exudative, usually small and unilateral, and tend not to be progressive or to persist beyond 7 days after formation.

The INR in this patient is not yet therapeutic, and therefore, the warfarin dose needs to be adjusted and the patient requires ongoing anticoagulation that relies on continuation of heparin.

The patient's acute presentation following a prolonged air trip is not uncommon in this era of long-distance travel. The mechanism of effusion formation in pulmonary embolism involves both increased hydrostatic pressure in the pulmonary circulation and increased permeability in the visceral pleural vasculature. Approximately 80% of effusions associated with pulmonary emboli are therefore exudative. They are also usually small (<1/3 of the hemithorax ) and unilateral and tend not to be progressive. The effusion in pulmonary embolism usually does not persist beyond 7 to 10 days after formation in the presence of underlying embolism.

The presence of a sanguineous or bloody effusion (erythrocyte count >100,000 cells/μL [100 × 109/L]) associated with pulmonary is not a contraindication to anticoagulant therapy. If a pleural effusion clearly increases in size during anticoagulant therapy, the development of hemothorax or an underlying infection should be excluded by thoracentesis. Insertion of an inferior vena cava filter should also be considered in such patients; however, in this patient anticoagulation should be maintained and placement of a vena cava filter is not indicated as the next management step in this case.

[ArchivalUser]

good question pacemaker and excellent pick darkhorse,,,,,,thats adds something to my brain bank of effusions in a case of PE....................thanks guys