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INSTRUCTIONS FOR THE DOCTOR

This is a short viva.

Please discuss your management of this situation with a GP colleague.

Scenario

You are on call and it is the end of the Saturday morning surgery. Your receptionist gives you a message from the laboratory to say that Mr Vincent Butler’s INR level is 5.7.

You find the following information in Mr Butler’s medical record:

  • Age

  • 62

  • Past medical history

  • Mitral valve replacement six years ago

  • Hypertension

  • Medication

  • Warfarin 4 mg, alternate day 5 mg

  • Ramipril 10 mg per day

  • Atorvastatin 20 mg per day

  • Allergies

  • Nil recorded

  • Immunisations

  • Nil recorded

  • Social history

  • Retired chef.

INSTRUCTIONS FOR THE FACILITATOR

This is a viva.

The doctor is expected to talk with you as a professional colleague.

During the viva please ensure you ask the following questions:

  1. What is your management of Mr Butler today?

  2. What are the common causes of poor INR control?

  3. What systems should there be in a practice to monitor the INR of patients on warfarin?

  4. You decide to do a locum in a remote Aboriginal community. Would that make any difference to your management of patients on warfarin?

The following information is in Mr Butler’s medical record:

  • Age

  • 62

  • Past medical history

  • Mitral valve replacement six years ago

  • Hypertension

  • Medication

  • Warfarin 4 mg, alternate day 5 mg

  • Ramipril 10 mg per day

  • Atorvastatin 20 mg per day

  • Allergies

  • Nil recorded

  • Immunisations

  • Nil recorded

  • Social history

  • Retired chef.

SUGGESTED APPROACH TO THE CASE

  1. Management of the high result

    Clarify result with laboratory—preferably in writing/fax

    Check that it is the correct result for the correct patient on the correct date

    Search notes for:

    • contact details—inform patient by phone if possible or via text message or through friends/family. If not by direct contact candidate must ensure that Mr Butler contacts you back to confirm receipt of the message and management plan. If not contactable may need to do home visit

    • clinical information—reason for being on warfarin, target INR1, any recent medication or dietary change likely to alter INR, pattern of INR control.2

    Management plan3—to discuss with Mr Butler

    • Plan for temporary cessation of warfarin, next test date and how to get results to find out next dose of warfarin

    • Reiterate indications that would require hospital assessment: prolonged bleeding from a cut or unexpected bleeding

    • Recommend quiet weekend, avoid contact sports

    • Question to determine what affected control.

  2. Common causes of poor INR control

    • Poorly calibrated machine/incorrect use of machine on point-of-care testing

    • Omissions or commissions taking warfarin, either deliberate or accidental

    • Medication interaction: patients should inform any prescriber that they are on warfarin, as NSAIDs and antibiotics (ciprofloxacin, metronidazole, doxycycline, erythromycin) are common causes of raised INR

    • Herbal products ...

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