CASE 7

 

PATIENT:  45 year-old woman

 

CLINICAL HISTORY

This patient was admitted with massive hemoptysis.  At the time of admission, she was receiving Coumadin (sodium warfarin) for superficial thrombophlebitis.  The patient’s prothrombin time was 21 seconds, although she had not taken Coumadin since the day preceding admission

 

MEDICAL HISTORY:  The patient had an episode of deep vein thrombosis after the birth of her second daughter when she was 30 years old.  The patient was placed on heparin, which was then followed by oral anticoagulants for 6 months.

 

After a spontaneous abortion at the age of 32, the patient was placed on oral contraceptives.  She subsequently experienced superficial left calf vein thrombophlebitis, and the oral contraceptives were discontinued.  Two months prior to this admission, patient developed superficial thrombophlebitis of the legs that were not associated with trauma.  Patient was started on Coumadin at that time.

 

FAMILY HISTORY:  The paternal grandfather, who died at 32 years of age, had a history of “swollen legs”.  The patient’s father had a pulmonary embolism at 27 years of age after appendectomy, and he died suddenly at 42 years of age after an attack of thrombophlebitis of the left leg.  Also, a cousin died at 39 years of age after several episodes of thrombophlebitis.  Another cousin, 63 years of age, had a number of problems with thrombotic disease, including a history of arterial embolism that necessitated amputation of the left leg at the knee.

 

DRUG HISTORY:  At the time of the initial evaluation, the patient was on no medication.

 

PHYSICAL EXAMINATION:  Superficial varices were noted over the legs.

 

SCREENING COAGULATION LABORATORY RESULTS

PT= 21 sec (Normal 8-11.5)

aPTT = 43 sec (Normal 24-37.5)

Plt= 315,000 /μL (Normal 150,000-350,000)