The patient which I have followed this entire week has an disorder which causes hypercoaguability, Antithrombin III Deficiency. Antithrombin works in our blood by inhibiting the formation of clots by inhibiting clotting factors II and X. When we give a patient Heparin, the drug works by enhancing the function of antithrombin III. So if a person has a deficiency in antithrombin III, they are in a hypercoaguable state; moreover, they are less responsive to Heparin therapy because there is a lower amount of antithrombin III available in the patient's blood available to enhance. This patient had bilateral PE and a large lower extremity DVT. There are no other significant medical problems, so this patient is a fairly straight-forward case. But what is interesting is her AT3 deficiency. AT3 Deficiency is most commonly a genetic mutation that is autosomal dominant inheritance (thus, the patient's children have a 50% chance of having this disorder since only the heterozygous AT3 deficiency is compatible with life). These patients are predisposed to clotting, so anything which increased risk of clots is discouraged (i.e. smoking, hormone/estrogen replacement, inactivity, overweight body mass, etc). Many years prior to this admission, the patient had a PE and DVT. This is common in patients with inherited hypercoaguability - recurrent thromboemboli. Our possible treatment plan consists of: enoxaparin (a low-molecular weight heparin) for 5-7 days at a higher-than-average dosage due to her decreased availability of antithrombin 3; coumadin with appropriate PT/INR monitoring and appropriate dietary modifications to stabilize vitamin K intake from day-to-day - this will be continued for the long term (for life or until something happens which would make coumadin contraindicated for her), and Inferior Vena Cava Filter placement (it "catches" the clots that travel from the deep veins in the legs towards the heart, thereby decreasing the likelihood that the clot would become lodged in the pulmonary arteries). This patient is so super sweet, she just melts my heart. I even have time to sit and talk to her. She asks my opinion (which I hesitate to give!), and I do my best to explain things more clearly and answer her questions. I've also given a lot of information on coumadin management, and printed out a few leaflets explaining her AT3 deficiency, how to manage coumadin, signs/symptoms of DVT/PE, etc. I've been with her to alleviate her anxiety, calm her fears, and explain things clearly. I can honestly say that this is the first patient that I have really made a connection with, and I feel personally responsible for her health care and well-being...which is terrifying!...but so rewarding. I love this. I love medicine. I actually just want to keep checking up on her, making sure she's fine, even when I'm at home. I just love this job!!!!!!!
And on to some amazingly great news:
Mike's Authorization for Employment was ACCEPTED today!!!!!!!
YAAAAAAAY he can now finally apply for jobs here in the states!! This was a huge reason why we decided to apply for the green card, so it's a happy day! AND it means that our green card application is being looked at - its not just sitting in a pile - so it might not be too long before we see that get approved as well. Yay!
