Question of the Week # 144 and 145

Q143) A 50 year old obese woman with history of uncontrolled Hypertension and congestive heart failure is admitted with complaints of palpitations for the past one week. Her symptoms have worsened over the past 24 hours. An electrocardiogram shows atrial fibrillation with rapid ventricular response.  After adequately controlling her heart rate with pharmacotherapy, warfarin therapy is initiated at 10mg per day and the patient is discharged. Three days after her discharge, patient presents to the ER with erythematous and painful lesion on her right thigh.

 About 1/3rd of  these patients tend to have an underlying abnormality which is :

A) Fat Malabsoprtion

B) Vitamin K deficiency

C) Protein C deficiency

D) Protein S deficiency

E) Antiphospholipid Antibody Syndrome

144) Which of the following step could have prevented patient’s symptoms in the above case:

A) Checking Factor VII level

B) Checking Protein C level

C) Checking Protein S level

D) Initiation of Warfarin at a low dose

E) Vitmain K Supplementation

6 Responses

  1. 143 d

    144 – d

  2. C) Protein C deficiency

  3. c,d

  4. protein c def.
    checking for protien c def.

  5. Patient has Protein “C” Deficiency, check for protein C deficiency.

    The reason why we don’t check for protein S is because the incidence of protein C is 1 in 300 cases Vs protein S which is 1 in 20,000.

    Generally, heparin prevents the skin necrosis if started with warfarin but that is not an option. We will not check Factor 7 because Protein C is a protease that results in the cleavage of factor Va and VIIIa and not VII. Initiation of warfarin at a low dose would not make a difference because patients are at risk in anyway, if they are not treated with the blood-thinning drug heparin before taking warfarin.

  6. CC. Question 144 shouldve included the answer “starting Heparin iv before Coumadin” since protein C level is not checked routinely unless there is a good reason before starting a/coagulation.

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