Early June - 52 yo BM admitted for acute AMI requiring cardiac cath and PTCA of LAD. Requires mechanical ventilation x 5 days, ICU x 7 days and in hospital x 10 days. ECHO prior to d/c reveals EF of approx 25%.
Late June - pt readmitted for W/U of persistent leukocytosis noted on earlier admission. Undergoes BM Bx with findings consistent with CML. Discharged to home after 3 days.
Early July (5 days post d/c) - Seen in walk-in clinic for non-productive cough and SOB. CXR clear. Dx: bronchitis
Mid July - symptoms persist/worse. Repeat CXR reveals new LLL effusion. Dx’ed with CHF and given diuretics. + PPD.
Early August - referred to Pulmonary Clinic for persistent cough, SOB and effusion. ? CA v. TB.
CASE 3 - 43 yo AA male truck driver who has bilateral knee injuries while playing basketball. Requires bilateral knee repairs requiring fixation of both lower extremities for 6 - 8 weeks. Received appropriate DVT prophylaxis during hospital stay. - Returns to the ED 4 weeks later with chest pain, SOB and hypoxemia. Has massive PE by CT angiogram and pulmonary hypertension/RV dilation by echocardiogram. - Given TPA with good clinical response.
Unexplained 50% decrease in platelets (even if absolute total > 150)
Positive test for Heparin antibodies
Activation assay (more relevant but more difficult)
begins early (few hours) after starting heparin
typically benign with plts usually staying > 100K. No Rx needed.
begins several days into treatment (unless previously sensitized)
High risk for thrombotic complications. Requires Rx.
Venous Thromboembolism Outpatient LMWH Enoxaparin sodium Unfractionated heparin $2,278 $5,323 Total mean costs per patient (CAN) P 0.0001 95% CI $2,012 to $4,050 O’Brien et al. Arch Int Med . 1999;159:2298-2304.