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Question 1 How would you manage patients on warfarin in the following four scenarios?
How would you manage patients on warfarin in the following four scenarios?
1- A 55 years old man with atrial fibrillation has an INR of 7 at his routine clinic appointment, having been stable over previous months, he has no bleeding problems.
2- You are called by a dental surgeon about 30-year-old women on a permanent anticoagulation after recurrent venous thrombosis. Her INR a week ago was 2.5 and the dentist wishes to extract a molar tooth right now.
3- A 65-year-old man on long term anticoagulation is admitted unconscious with intracranial hemorrhage. His INR is 12.
4- A surgeon calls about a man on warfarin with a metallic mitral heart valve and a current INR of 4. He would like to perform elective cholecystectomy at some time in the next few weeks.
· A 3-year-old girl was referred to your hospital following presentation at her local hospital with headache and seizures. A CT scan had revealed a central mass. The neurosurgeon decided that mass was not respectable but that a tissue diagnosis was required.
· It was his normal practice to perform pre-operative coagulation screening. The following results were obtained
· APTT 89 seconds (normal 24-34 S)
· PT 13.5 seconds (normal 12-14 S)
· APTT 50% mixture with normal plasma is 76 seconds
· Thrombin time 11 seconds (normal 11 S)
· Fibrinogen 3.2 g/l
· Full blood count Hb 113 g/l; WBC 10.4X10^9; Platelets 345 X10^9
· The operation was postponed pending further investigations.
1- What test would you perform to reach the diagnosis?
2- What advice would you give to the surgeon?