CASE 10

PATIENT: 67-year-old man

CHIEF COMPLAINT: This patient was admitted with a provisional diagnosis of deep-vein thrombosis and pulmonary embolus. When he was seen in the emergency room, he reported shortness of breath and chest pain. He also described a bout of coughing, during which fresh blood was expectorated, immediately before his hospital visit.

MEDICAL HISTORY: Noncontributory

FAMILY HISTORY: Noncontributory

DRUG HISTORY: The patient had taken cimetidine for peptic ulcer disease.

PHYSICAL EXAMINATION: The pulse was rapid at 110 pulsations per minute, and the respiratory rate was also increased at 35 inspirations per minute. Blood pressure was 100/60. In addition, the legs revealed a trace of pitting edema, with localized tenderness being noted in the upper portion of the right thigh.

LABORATORY RESULTS (on admission, Day 1)

	Patient	Normal
Prothrombin time	10 seconds	8-11.5 seconds
aPTT	30 seconds	24-37.5 seconds
Platelet count	310,000/μl	150,000-350,00/μl

HOSPTIAL COURSE: The patient was evaluated with a ventilation perfusion scan together with a pulmonary arteriogram, and a diagnosis of pulmonary embolism was established. The patient was started on heparin, 6,000 units every four hours, after a loading dose of 20,000 units. He was continued on heparin for 5 days, at which time oozing from venipuncture sites was noted. The following laboratory results were obtained:

LABORATORY RESULTS (Day 5)

	Patient	Normal
Prothrombin time	13 seconds	8-11.5 seconds
aPTT	70 seconds	24-37.5 seconds
Platelet count	10,500/μl	150,000-350,00/μl

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