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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify the signs, symptoms, and risk factors associated with pulmonary embolism (PE).

  • Evaluate a patient for heparin-induced thrombocytopenia (HIT).

  • Select an appropriate anticoagulant for the treatment of PE complicated by HIT.

  • Recommend a pharmacotherapeutic plan to initiate and monitor anticoagulation for the treatment of PE complicated by HIT.

  • Provide patient education on anticoagulation therapy.

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PATIENT PRESENTATION

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Chief Complaint

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“I’m having chest pain, and I can’t catch my breath.”

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HPI

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Mary Anton is a 70-year-old woman who arrives at the hospital’s emergency department by ambulance transfer from her home. The patient is S/P right TKR (postoperative day #10) for severe osteoarthritis. She was discharged from the hospital’s orthopedic nursing unit 4 days ago with a prescription for enoxaparin for DVT prophylaxis. The patient was scheduled to receive physical therapy at a local rehabilitation center; however, she canceled therapy due to pain. She has been inactive at home with the exception of completing her activities of daily living with the assistance of her husband. This morning, the patient developed sharp chest pain and shortness of breath while watching television. She denies nausea, vomiting, and diaphoresis. The patient has a nonproductive cough. She is anxious and also complains of pain in her right knee and right lower extremity.

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PMH

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  • HTN × 30 years

  • Dyslipidemia × 25 years

  • Chronic stable angina × 2 years (negative regadenoson stress test 2 months ago)

  • CKD secondary to previously uncontrolled HTN, stage 4 (baseline creatinine 1.8–2.0 mg/dL)

  • Osteoarthritis

  • Obesity

  • S/P TKR right leg (postoperative day #10)

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FH

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  • Father died at age 74 (lung CA)

  • Mother died at age 89 (MI)

  • No siblings

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SH

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The patient is retired. She lives at home with her husband. Prior to surgery, she avoided most physical activity due to severe osteoarthritis. Negative for tobacco abuse. Denies alcohol use.

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Meds

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Home medications:

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  • Aspirin 81 mg PO once daily

  • Metoprolol tartrate 50 mg PO BID

  • Amlodipine 10 mg PO once daily

  • Hydralazine 25 mg PO TID

  • Atorvastatin 20 mg PO once daily

  • Nitroglycerin 0.4 mg sublingually PRN chest pain

  • Calcium acetate 1334 mg PO TID with meals

  • Enoxaparin 30 mg SC Q 24 hours

  • Oxycodone sustained release 20 mg PO Q 12 hours

  • Oxycodone immediate release 5 mg PO Q 6 hours PRN pain

  • Docusate 100 mg PO QHS

  • Sennosides 17.2 mg PO QHS

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All

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Lisinopril (angioedema).

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ROS

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Positive for shortness of breath and nonproductive cough. Positive for sharp chest pain at rest. The pain does not radiate and is not reproducible by touch. No palpitations, diaphoresis, nausea, vomiting, or ...

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