Supportive and Preventive Medicine

Patient Cases

A 93-year-old man (weight 45 kg) confined to his bed is admitted from a nursing home with a chronic

obstructive pulmonary disease exacerbation requiring mechanical ventilation. He has a history of diabetes

and heart failure. His laboratory values are all within normal limits except for BUN 35 mg/dL and SCr 2.8

mg/dL (baseline 0.5). Which would be the most appropriate recommendation for VTE prophylaxis in this

patient?

Questions 6 and 7 pertain to the following case.

A 55-year-old man (weight 60 kg) with a medical history of diabetes, hyperlipidemia, and a DVT 4 months ago

secondary to lower-extremity trauma is admitted today to the ICU for acute respiratory failure from influenza

virus. His current laboratory values are as follows: WBC 13.1 x 103 cells/mm3, Plt 250,000/mm3, BUN 13 mg/dL,

SCr 0.9 mg/dL, INR 1.2, AST 22 IU/mL, and ALT 11 IU/mL. His current medication regimen includes fentanyl

and midazolam boluses for pain and agitation, piperacillin/tazobactam, vancomycin, regular insulin infusion, SUP,

and a heparin drip. Five days later, the patient remains intubated on the same medications. At this time, his Plt

has decreased to 112,000/mm3, and his BUN and SCr have increased to 45 mg/dL and 2.7 mg/dL, respectively.

The team sends a heparin-PF4 immunoassay; however, the results will not return for 48 hours.

Which would be the best course of action?

Three days later, both the heparin-PF4 immunoassay and the serotonin release assay return positive, and the

patient has a new DVT. The team wants to initiate warfarin. The patient’s current Plt is 130,000/mm3. Which

would be the most appropriate response?

of patients and their families facing the problems associated with life-threatening illness, through the

prevention and relief of suffering by means of early identification and impeccable assessment and treatment

of pain and other problems, physical, psychosocial, and spiritual” (Global Atlas of Palliative Care at the End

of Life).