By Stephen Hoole, Andrew Fry, Daniel Hodson, Rachel Davies
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Additional info for Cases for PACES, 2nd edition
Case 12 Dear Dr, I would be grateful for your advice on this 40-year-old male who was diagnosed with antiphospholipid syndrome following a pulmonary embolus 3 years ago. 5) was advised then. Recently he seems increasingly resistant to warfarin requiring doses of 15 mg daily. Despite this his INR is frequently subtherapeutic. In addition, on one occasion he has been admitted via A&E for INR > 20. I have checked his antiphospholipid antibody levels which remain greatly elevated and would be grateful for you advise on his management.
I would be grateful for your urgent assessment. Case 4 Dear Dr, Thank you for seeing this 35-year-old teacher urgently. I am concerned she has had a pulmonary embolus. She developed central pleuritic chest pain during the course of yesterday; however, she has felt generally unwell for a week. She was on the combined oral contraceptive pill until 1 year ago. She currently takes fluoxetine for depression and nifedipine for Raynaud’s syndrome. On examination she was a little breathless. Pulse 100; BP 170/100.
You have no symptoms of hot or cold intolerance and do not suffer with palpitations or tremor and your bowels are normal. You do not suffer from dizziness or faints or excessive thirst. You do not suffer with indigestion. You do not have headaches. You do not have a problem with your vision, but recently crashed your car because ‘a car came out of no-where’. You have noticed that you have been lactating over the past few weeks. You are embarrassed but also quite worried about this and would only divulge this personal information if asked in a direct but sensitive way.