Case 139 – short case 2

You are the haematologist on call and phoned at 5pm on a Friday about a 75 year old lady who presented to the acute admissions unit with confusion. She was diagnosed with Hypercalcaemia and a subsequent CT is suggestive of metastatic Lung Adenocarcinoma. She has a past medical history of Type two diabetes, AF on Apixiban, Gallstones, Diverticular disease and has an elevated BMI with a weight of 130kg.

The medical team contact you as she has had a staging CT that shows a segmental PE in right lung and a CT Brain that shows probable cerebellar metastasis with one metastasis showing possible small haemorrhage. Her right leg is swollen and clinically there is suspicion of a DVT.

They are concerned about the new VTE while she is “on Apixiban” and had planned to change her to treatment dose LMWH but wanted your approval for this before starting this given the possible bleed on CT Head.

They tell you her FBC is normal and her coagulation screen is normal apart from an elevated fibrinogen and D-Dimer. Her renal function is Normal.

What are your initial thoughts regarding anticoagulation?

Are there any other investigations that may help in this case?

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