A 54-year women is 3 days post abdominal surgery for removal of a cancerous mass in her abdomen. She develops acute shortness of breath associated with tachycardia and hypotension.

A 54-year women is 3 days post abdominal surgery for removal of a cancerous mass in her abdomen. She develops acute shortness of breath associated with tachycardia and hypotension. CT Scan of the chest is positive for multiple small pulmonary embolism. What medication and dosing would you order initially to treat the pulmonary embolism?

QUESTION 2A 45-year-old male is evaluated for complaints of severe low back and left leg pain. His MRI shows a herniated disk at L4L5. He has been recommended for a lumbar laminectomy surgery to treat the herniated disk. The patient had a cardiac stent placed 3 weeks ago and is currently on Plavix post procedure. When will the patient be able to have the lumbar surgery?

QUESTION 3A 25-year-old male is in the Surgical Intensive Care Unit (SICU) following a motor vehicle crash (MVC) where he sustained multiple life-threatening injuries including a ruptured spleen, chest trauma, and bilateral femur fractures. He has a triple lumen central venous catheter (CVC) for monitoring his central venous pressure, administration of medications and blood products, as well as total parenteral nutrition. Per hospital protocol, he is receiving an unfractionated heparin 1:1000 flush after administration of each of the triple antibiotics that have been ordered to maintain patency of the lumens. Seven days post injury, the APRN in the SICU is reviewing the patient’s morning labs and notes that his platelet count has dropped precipitously to 50,000 /mm3 from 148,000/mm3 two days ago. Hemoglobin and hematocrit are normal and there is no evidence of bleeding.

 What do you suspect is the cause of the thrombocytopenia? How would you treat it?

QUESTION 4A 56-year-old male is taking warfarin 3 mg daily for treatment of a DVT / PE. He has his INR monitored every 4 weeks. His INR today is 3.1 and his last INR is 2.9. There have been no changes in his medications or health.

What is his INR goal? How would you manage his INR today?

QUESTION 5A 26-year-old male was injured in a motorcycle crash 3 days ago. He sustained an acute subdural hematoma, acetabular fracture, and L2 fracture with spinal cord injury and resulting paralysis. He has a warm swollen right lower leg. Duplex ultrasound of the right lower leg is positive. What is the best treatment for this patient?

QUESTION 6A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection. The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were:

 CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low.

 Based on the clinical presentation and laboratory data provided, what is your working diagnosis?

QUESTION 7A 16-year-old male is brought to the Urgent Care by her mother who states that the girl has had an abnormal number of bruises and “funny looking red splotches” on her legs. Bruises were noted about 2 weeks ago and have increased in number since this time. There is no history of trauma to explain the bruising. Past medical history not remarkable and she takes no medications. The mother does state the girl is recovering from a “bad case of mono” and was on bedrest at home for the past 3 weeks. The girl noticed that her gums were slightly bleeding when she brushed her teeth that morning.

 Lab work completed show a normal hemoglobin and hematocrit with normal white blood cell (WBC) count and differential. Platelet count of 50,000/mm3 was the only abnormal finding. The staff also noticed that the venipuncture site oozed for a few minutes after pressure was released. Immune thrombocytopenia purpura (ITP) is suspected. What additional diagnostics should be ordered? If this diagnosis is confirmed, how would you treat it?

QUESTION 8A 44-year-old female with a mechanical mitral heart valve is scheduled for elective abdominal surgery next week. The patient currently takes warfarin 5 mg daily for prevention of thrombus. The patient is high risk for blood clot formation and needs to be bridged once her warfarin is stopped for surgery. How would you manage this patient’s anticoagulants during the pre- and post-operative period?

QUESTION 9A 64-year-old man diagnosed with a pulmonary embolism is currently on warfarin. His INR readings have been very inconsistent, and the decision is made to change his medication to Rivaroxaban (Xarelto). What dose should be initiated and how would you discontinue the warfarin?

QUESTION 10Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She states she has been taking it easy and laying around her home for most of the last week so it would heal. Yesterday she noticed that her calf was sorer than it had been, and her R foot and ankle were more swollen than they had been. She came to urgent care today because she was afraid that the injury was worse than she thought it was.

T 99.2 BP 128/77 HR 88 RR 18 Wt 126 pounds

Heart S1S2 regular rate and rhythm, Lungs clear, Abdomen soft

R ankle is swollen but not discolored. 1-2+ edema noted Dorsiflexion causes some discomfort in the ankle and calf area.

Pedal pulses equal bilaterally

The APRN orders a duplex ultrasound of the right leg. Radiology reports that the ultrasound is positive for a deep vein thrombosis. How would you manage this patient (include labs and meds)?

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