Pulmonary Embolism And Anticoagulation Follow-Up Practice Test

A 47-year-old man on long-term anticoagulation for PE 3 months ago (provoked by long-haul flight and obesity) presents with new pleuritic chest pain and dyspnea on exertion. He is taking apixaban 5 mg twice daily; he admits missing several evening doses over the last week. No hemoptysis. Vitals: BP 132/80, HR 108, RR 22, SpO2 93% RA. Exam shows mild right calf tenderness. Labs: INR 1.1, creatinine 0.9 mg/dL (eGFR 95 mL/min/1.73 m²), troponin negative. He has no contraindications to contrast. What is the most appropriate next step in management for this patient?

A 55-year-old woman with recurrent unprovoked PE (two episodes, last 14 months ago) presents for routine anticoagulation follow-up. Risk factors include prior estrogen-containing OCP use (stopped), obesity, and strong family history of VTE; she has no active cancer. She is on warfarin with target INR 2.0–3.0, monitored every 4 weeks; last two INRs were 2.4 and 2.6. She now reports 3 days of dark stools, lightheadedness on standing, and increased bruising; no chest pain or dyspnea. Vitals: BP 104/66, HR 102, SpO2 98% RA. Exam shows conjunctival pallor and ecchymoses. Labs today: INR 3.8, Hgb 8.7 g/dL (baseline 12.1), platelets 210k, BUN 34 mg/dL, creatinine 1.3 mg/dL (eGFR 52 mL/min/1.73 m²). She recently started ibuprofen for back pain. What is the most appropriate next step in management for this patient?