Posted by ddd from IP 220.131.79.224 on June 25, 2008 at 10:31:11:
A 49-year-old woman presents to the emergency department with increased fatigue and dyspnea on exertion for the past 6 months. She underwent a mechanical mitral valve replacement 10 years previously. She has been on warfarin therapy since that time, with a goal INR of 2.5 to 3.5. Her dosage is 5 mg daily. She states that she takes her warfarin “most of the time,” and that her INR has been “pretty good”; records of her anticoagulation monitoring are not available.
On physical examination, her weight is 62 kg (137 lb), blood pressure is 116/72 mm Hg, and her pulse is 98/min and irregularly irregular. There is 12 cm jugular venous distention with normal carotid upstrokes. Lungs are clear. On cardiac auscultation, the S1 is soft, the S2 is physiologically split, and there is a grade 3/6 holosystolic murmur at the apex radiating to the axilla. Her INR today is 1.4. A transesophageal echocardiogram is scheduled.
Which is the most appropriate therapy while the transesophageal echocardiogram is pending?
A Give additional warfarin
B Add aspirin
C Start enoxaparin
D Begin intravenous heparin
E Give alteplas