Week 8 - Breathlessness in a 37 year old woman

Question 1

What other history should be sought?

Answer 1

Question 2

What are the possible causes of her breathlessness?

Answer 2

Question 3

What features would you look for on examination?

Answer 3

Question 4

What 5 investigations are you going to arrange at this stage?

Answer 4

Question 5

Comment on the blood gases. What is the imaging investigation and what does it show?

Answer 5

Question 6

What action do you take for patients with a confirmed PE on CT-pulmonary angiogram?

Answer 6

Question 7

Describe how you would prescribe the warfarin and how you would monitor its effects. How long should this woman stay on warfarin?

Answer 7

Question 8

What advice would you give before discharge to a patient whom you have commenced on warfarin?

Answer 8

Question 9

The woman’s INR is maintained within the therapeutic range. Two months after her hospitalization, she presents to the emergency department with an epistaxis. The left nostril has been bleeding for 50 minutes and she has been unable to stop it with simple pressure. She has been unwell with bronchitis and production of yellow sputum for 4 days. Her local doctor prescribed her a course of oral amoxicillin 3 days earlier. What do you think has happened?

Answer 9

Question 10

Her IN is 8.1. The nostril is packed and she is given 3mg IV vitamin K and advised to hold further warfarin. What are the potential hazards of IV vitamin K? Why can’t it be given as an IM injection?

Answer 10

Question 11

Definition of a Pulmonary Embolism?

Answer 11

Question 12

Risk factors for PE?

Answer 12

Question 13

Clinical presentation of PE?

Answer 13

Question 14

Which 6 investigations should be performed prior to commencing acute anticoagulant therapy for proximal DVT and PE?

Answer 14

Before starting anticoagulant therapy, collect blood to measure the patient’s:
1. Activated partial thromboplastin time (APTT)
2. International normalised ratio (INR)
3. Full blood count
4. Kidney function
5. Liver biochemistry
6. Beta human chorionic gonadotrophin (hCG) test for women of childbearing age.

Question 15

3 examples of NOACs? Which patients can you not use these in?

Answer 15

Do not use a NOAC (eg apixaban, dabigatran, rivaroxaban) in a patient with severe kidney impairment; use warfarin or a parenteral anticoagulant.

Question 16

What are the preferred pharmacological therapies for treating proximal DVT and PE?

Answer 16

Oral factor Xa inhibitors (eg apixaban, rivaroxaban) are preferred to dabigatran or warfarin to treat proximal DVT and PE because they do not require parenteral anticoagulation for initiation. Apixaban and rivaroxaban do not require routine anticoagulation monitoring; however, using the correct dose is vital because underdosing may not provide adequate anticoagulation.

Question 17

Describe a suitable pharmacological regimens to treat VTE?

Answer 17

Question 18

List 6 factors predicting recurrence of VTE?

Answer 18