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Monitoring of Anticoagulation Treatment with Warfarin

A 28-year-old married Caucasian woman.

Family history:
Parents are alive and healthy.

Personal history:
She had a deep venous thrombosis in her left leg 2 years ago, otherwise she has been healthy, no surgery in personal history.

This young woman was admitted to the Department of Internal Medicine for a painful swelling of the right lower extremity, which had been present for 3 days. These symptoms arose after a long bike trip. During the last two days she also had two episodes of dyspnea twice a day. As mentioned above, she had suffered from deep venous thrombosis in the left leg complicated by pulmonary embolism 2 years ago. After this thrombotic event she discontinued taking oral contraceptive pills and anticoagulation treatment with warfarin (4-hydroxycoumarin) 5 mg daily was started. She decided to withdraw warfarin 6 days ago. INR at the time of admission to the hospital was 1.4. The medical report from the previous event was not available, because she was treated at a local district hospital.

Physical examination:
Normosthenic habitus, body weight 60 kg, blood pressure 120/80, heart rate 80/min, no signs of dyspnea. Physical finding was normal except for swelling of the right extremity - below the knee with a positive plantar and Homan's signs.

Laboratory tests:
A. Sinus rhythm, heart rate 76/min.
B. X - ray examination of the lungs and the heart did not reveal any abnormality.
C. INR = 1.4.
D. APTT : control plasma time = 32.1 s., patient plasma time 33.6 s.
E. D- fibrinogen dimer = 1000 µg/ml.
F. pH =7.4, pO2 = 9.6 kPa, pCO2 = 3.5 kPa.
G. Venous ultrasound revealed deep venous thrombosis in the right extremity.
H. Perfusion - lung scanning did not detect any diminished perfusion.