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PROBLEM: Probable Coumadin hypersensitivity.

HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty. At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity. However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels. Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise. Her prothrombin time is now 83.3 seconds with an INR of 6.52. Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.

SOCIAL HISTORY: The patient is originally from Maine. She has lived in Arizona for 4 years. She has had 2 children; however, only one is living. She had one child died from complications of ulcerative colitis. She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.

CHILDHOOD HISTORY: Negative for rheumatic fever. The patient has usual childhood illnesses.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: The patient's mother died from gastric cancer. She had a brother who died from mesothelioma. He did have a positive asbestos exposure working in the shipyards. The patient's father died from motor vehicle accident. She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.

HABITS: No use of ethanol, tobacco, illicit, or recreational substances.

ADULT MEDICAL PROBLEMS: The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X. In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.

SURGERIES: The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.

MEDICATIONS: The patient's medications on admission include:
1. Fosamax.
2. TriCor.
3. Gabapentin.
4. Hydrochlorothiazide.
5. Labetalol.
6. Benicar.
7. Crestor.
8. Detrol.

REVIEW OF SYSTEMS: Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time. She is arousable, but not particularly conversant.

OBSERVATIONS:
GENERAL: The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.
HEENT: Pupils were equal, round, and reactive to light and accommodation. Extraocular muscles are grossly intact. Oropharynx benign.
NECK: Supple. Full range of motion without bruits or thyromegaly.
LUNGS: Clear to auscultation and percussion.
BACK: Without spine or CVA tenderness.
HEART: Regular rate and rhythm without murmurs, rubs, thrills, or heaves.
ABDOMEN: Soft and nontender. Positive bowel sounds without mass or visceromegaly.
LYMPHATIC: No appreciable adenopathy.
EXTREMITIES: The patient has some postoperative fullness involving her left knee. She has a dressing over the left knee.
SKIN: Without lesions.
NEURO: Unable to assess in light of post morphine obtunded state.

ASSESSMENT: Hypersensitivity to Coumadin.

PLAN: Gave the patient vitamin K at this time. Literature suggested oral vitamin K is actually more efficacious than parenteral. However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion. Repeat prothrombin time and INR in a.m. Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.

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