Problem
ST is a 5'9", 130 kg 77 year old female presenting to you today with complaints of progressive weakness, cramping, and diarrhea lasting several days. She was seen in the local ER the day before and given IV hydration. She was diagnosed with viral gastroenteritis, had some labs drawn and was sent home. Her s/s continue and she feels like she may pass out, prompting her visit to you today.
Labs from the ER show that her INR was 5.8. She was told to hold her Coumadin last night. Additional labs from the ER show everything was normal except glucose 158, BUN 87, Creatinine 3.63, CK 194, WBC 13.2, and platelets 515.
VITALS: 112/78, HR 116, RR 18, Pulse ox 98%, Temp 98.1 orally
PMH: HTN, hyperlipidemia, afib, hyperglycemia, diverticulitis, GERD
MEDS: Warfarin 10 mg on W, 7.5 mg all other days, Verapamil 120 mg po daily, Lisinopril 5 mg po daily, Simvastatin 80 mg po qhs, HCTZ 12.5 mg qd, Omeprazole 20 mg po qam , Omega-3-fatty acids OTC qd (she reports that she takes 4 pills divided bid)
NKDA
ROS: c/o generalized weakness, States that she has a poor appetite for 3 days, c/o muscle aching in her low back and legs, Denies recent ill contacts, Denies fever, Denies abd pain except for "cramp" before he has diarrhea, Denies blood in stool.
A. What concerns do you have given ST's presentation, PMH, and medications? What other questions would you ask ST?
B. When should her INR be checked again? How did you determine that? Discuss the half-life and mechanism of action of Coumadin. What is your plan for her Coumadin today?
C. Describe possibilities for the abnormal labs seen in the ER. What are her possible differential diagnoses? Why would the ER order a CK?
D. What treatment does this patient need? Why?
E. What changes (if any) are needed with her medication profile once she is well? Justify your changes.
F. What patient education does this patient need going forward?
G. What health maintenance would you discuss at this visit and when would you follow up next?