In a patient with a mechanical mitral valve replacement who is taking warfarin (Coumadin), the recommended INR range is:
Correct Answer D:
Most conditions (DVT or PE, atrial fibrillation) requiring warfarin therapy are adequately treated at INR values between 2.0 and 3.0; Patients with mechanical heart valves, especially mitral valves, may benefit from higher values (up to 3.5). Patients with thrombophilia due to antiphospholipid antibody syndrome may require a higher INR (3.0-4.0) for optimal therapy.
Warfarin is used for prophylaxis and treatment of venous thrombosis and its extension, prophylaxis and treatment of pulmonary embolism, prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation and/or cardiac valve replacement, and as an adjunct in the treatment of coronary occlusion.
What is its mechanism of action?
Warfarin is a coumarin-derivative anticoagulant that alters the synthesis of blood coagulation factors II (prothrombin), VII, IX, and X in the liver by interfering with the action of vitamin K. Warfarin inhibits epoxide reductase, thereby diminishing available vitamin K amounts and inhibiting production of functioning coagulation factors.
A man develops the following rash. See picture:
You diagnose him with an intertriginous candida infection.
All of the following treatments are appropriate, except:
Candidiasis of intertriginous skin occurs as poorly marginated, bright red plaques with satellite papules and pustules scattered around the periphery of the main lesion. Candidiasis is most commonly seen in the groin but also occasionally occurs in the axillary folds and interdigital web spaces. In men, groin lesions are located in the inguinal-scrotal fold with later involvement of the inner thighs, gluteal cleft, and scrotum. In women, Candida vaginitis usually precedes involvement of the labia minora and majora. Spread subsequently occurs to the inner thighs and gluteal cleft. Pruritus is generally present.
A clinical diagnosis can be confirmed by KOH preparations or cultures. These studies are more likely to be positive if they are performed on material recovered from intact pustules. Topical imidazoles (clotrimazole, ketoconazole, miconazole) applied twice a day are effective in the treatment of candidiasis. In those patients for whom inflammation is prominent or pruritus is severe, the addition of a topically applied steroid such as hydrocortisone reduces the discomfort and shortens the time for healing. Topical drying agents also play an important role in the treatment of intertrigo, as moisture and maceration are key aspects of the pathogenesis of this disorder. Various agents have been employed to keep the skin folds dry, clean, and cool. These include antifungal powders (including miconazole, nystatin, undecylenic acid, tolnaftate, and 12% benzoic acid), aluminum sulfate calcium acetate solution, gentian violet solution, carbol-fuchsin solution, and antiseptic drying agents such as potassium permanganate solution.
Orally administered amphotericin (choice D) or ketoconazole are only rarely indicated in uncomplicated cases.
A man has a semen analysis done. It shows abnormal motility and shape, and a total sperm count of 950,000 sperm (normal sperm count is greater than 20,000,000).
What do you advise him about his future fertility?
Abnormal morphology (shape) and motility can prevent the sperm from reaching the egg. The sperm need motility to be able to swim well and survive for a number of hours in the female reproductive tract. If they do meet, abnormal-looking sperm might be incapable of fertilization.
The motility of this man’s sperm is poor and therefore he is unlikely to be able to be fertile. In addition, infertility specialists have stated that 1 million motile sperm is the minimum amount of sperm associated with a reasonable chance of pregnancy success at intrauterine insemination.
However in-vitro fertilization (IVF) can be used to treat infertility due to his oligospermia. The procedure would involve controlled ovarian hyperstimulation, oocyte retrieval, fertilization with sperm, embryo culture, and embryo transfer.
Impotence is defined as an inability to achieve and/or maintain an erection.
You suspect a secondary cause in one of your patients who has developed hypertension.
Which of the following tests would not be part of your diagnostic work-up?
Correct Answer B:
Only 5% of causes of hypertension are from a secondary cause. Remember the mnemonic C.H.A.P.S. for the causes of secondary hypertension. Those are Cushing's, Hyperaldosteronism, Aortic coarctation, Pheochromocytoma, Stenosis of renal artery.
The diagnostic tests used to work up the above causes of secondary hypertension are 24 hour urinary cortisol level, basic metabolic panel, CT imaging, urinary catecholamines, renal ultrasound for Cushing's, Hyperaldosteronism, Aortic coarctation, Pheochromocytoma and Stenosis of renal artery, respectively.
5-hydroxyindoleacetic acid (5-HIAA) (choice B) is a break-down product of the chemical messenger serotonin in the urine. 5-HIAA levels to detect tumors in the digestive tract (carcinoid tumors).
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