In conjunction with a review of the literature and discourse with the cardiology and oncology services, his risk of significant bleeding on coumadin with known liver metastases was thought equal to his risk of stroke off coumadin. In discussing his preferences for health states, his fear of mental incapacity and other potential sequelae of stroke far outweighed his disutility for a bleeding complication of the coumadin. These preferences were so strong that coumadin remained the preferred treatment modality even when aspirin was presented as an option. While the patient initially desired cessation of coumadin, this decision changed following the presentation of a simple decision tree and open discussion of his preferences. DISCUSSION: Decision analysis allows for the implicit decisions made everyday in clinical medicine to be made more explicit. The process of SMDM is often very illuminating, as it encourages better communication between patient and physician as they consider the consequences of a particular medical decision together. These consequences include the probabilities of health outcomes and the values, or utilities, that the patient places on these outcomes. Explicit knowledge of patient utilities may have a major impact on the medical decision particularly in a setting such as this one in which quality of life may be valued over life expectancy. SMDM is an excellent way to engage patients in the important dialogue needed to best inform medical decision making. Heparin infusion was discontinued and warfarin was continued. On the same day he had a burning pain over his right shoulder and forearm. Day 6, well demarcated edema and erythema of his right shoulder and forearm and later purpura and skin necrosis occurred. Warfarin was discontinued and he was offered lepirudin. Biopsy of the skin confirmed anticoagulant related skin necrosis. Day 11, platelet count increased to 150. Platelet factor 4 antibody was positive confirming heparin induced thrombocytopenia (HIT). The liver biopsy showed metastatic adenocarcinoma. DISCUSSION: Warfarin skin necrosis is a rare complication but could lead to extensive skin loss with its associated problems such as is seen in major burns. The patient usually complains of pain of the affected area and this should prompt the physician to consider it in any patient on anticoagulation who has unexplained cutaneous pain. It may be minimized by discontinuing the warfarin and substituting with heparin, heparinoids or lepirudin if anticoagulation is needed. If INR is high, reverse anticoagulation. Avoid initial``loading'' dose of warfarin because this will lead to rapid depletion of protein C leading to a relatively hypercoagulable state. This risk appears to be particularly high in inherited hypercoagulable states and in patients with HIT. Heparin skin necrosis may occur with all types of heparin and could be at or away from the site of injection. Antibodies to heparin-platelet-factor 4 is suggestive. Give warfarin or lepirudin if needed. It is not possible to tell if this patient had warfarin or heparin skin necrosis. A method of distinguishing these two conditions is needed as treatment is different. week history of increasing confusion and 3 day history of right-sided frontal headache. His medications included thyroxine, oxybutynin, and theophylline. One week following recent knee surgery, he stated that his energy level was decreased and he was having persistent memory difficulties. Physical examination was unremarkable except for delirium and a resting tremor. The patient was alert, but oriented only to self and location. He had difficulty cooperating with the examination and was easily distracted from tasks. He was admitted to the hospital, where outpatient medications were restarted. Chemistry panel, CBC, LFT's, thyroid function tests, blood cultures, and cardiac enzymes were all normal. Theophylline level was high normal (19.9 mg/L). An EKG was read as sinus arrhythmia. A head CT showed ventriculomegaly with no intracranial bleed or mass. Results of lumbar puncture, EEG, MRI of the brain, and overnight pulse oximetry were nondiagnostic. On day 4 of hospitalization, confusion persisted. The patient experienced a 9 beat run of ventricular tachycardia and a cardiology consult was obtained. Review of EKG's and a rhythm strip revealed multifocal atrial tachcardia. A theophylline level was obtained and reported at 39 mg/L. Theophylline was discontinued. Over the next 7 days, the patient's mental status gradually cleared and he was discharged. DISCUSSION: Theophylline has a narrow therapeutic index (10 to 20 mg/L). Hypotension, cardiac arrhythmias, and seizures have been reported in association with toxicity. Levels often do not correspond to symptoms in chronic toxicity. Treatment is mainly supportive, although dialysis is often used in management of severe toxicity. The case illustrates: 1) the broad differential diagnosis and resource intensive evaluation of delirium in the elderly and 2) the insidious nature of chronic poisoning from a prescribed medication. A bladder scan demonstrated a residual urine of greater than 800 cc; bladder catheterization produced one liter of clear, yellow urine. Urinalysis was within normal limits. A review of the patient's medication list revealed that he had most recently been prescribed phenylpropanolamine and guaifenesin and had also been taking oxybutinin for``incontinence''. DISCUSSION: Benign prostatic hypertrophy (BPH) is a common problem, ranging from 40% ± 50% in males 51-60 years old, to over 80% in males above 80 years of age. Males with BPH have symptoms suggestive of overflow incontinence. Pharmacologic therapy includes antiadrenergic agents to assist with detrusor contraction and relaxation of the urinary sphincter. In addition, current literature provides some evidence for 5-alpha reductase inhibitors (finasteride) to decrease testosterone-dependent prostate gland enlargement. Phenylephrine, a popular over the counter and prescription medication, is commonly used as decongestant. It has been associated with acute urinary retention. It would follow that phenylpropanolamine (PPA), also a sympathomimetic, has similar capabilities. In this scenario, the patient's BPH in combination with PPA and the anticholinergic effect of the oxybutinin precipitated acute bladder outlet obstruction and anuria. Although PPA has been taken off the market recently, other sympathomimetic drugs can be inferred as equally hazardous in these patients. One of the many ways to prevent adverse outcomes from polypharmacy is to take a medication history every time one sees a patient and to be coginzant of potential adverse medication interactions. By reviewing all current medications, we may reduce iatrogenesis. DVT but an MRI demonstrated extensive soft tissue bleeding. Anticoagulation was withheld and her coagulopathy resolved as the hyperthyroid state was treated. DISCUSSION: Atrial fibrillation (AF) is a common arrhythmia, found in 1% of patients over age of 60. It is the most common cardiac condition associated with cerebral embolism. Underlying hyperthyroidism occurs in up to 12% of patients with this arrhythmia and therefore, a TSH is recommended in patients presenting with new onset AF. Our patient had an embolic right middle cerebral artery stroke due to AF and her AF was undoubtedly due to unrecognized hyperthyroidism. In addition, an atypical manifestation of hyperthyroidism was present. As has been reported in the literature, the hypermetabolic state of hyperthyroidism, exacerbated by a recent iodine load from her CT scan, led to consumption of clotting factors and a clinically relevant coagulatopathy which resolved with treatment of the hyperthyroid state. Finally, in this patient, the extrinsic compression of the venous system by the bleed was initially incorrectly interpreted as a DVT. Only by careful physical exam and attention to pathophysiologic and laboratory details of the case was potentially harmful treatment with heparin avoided.