Hematology Bleeding Disorders: Review Questions Richard S. Stein, MD, FACP Dr. Stein is an Associate Professor of Medicine, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN. Choose the single best answer for each question.
	Questions 1 and 2 refer to the following case study. A 73-year-old woman who has been receiving 5 mg of warfarin daily for 3 months because of a pulmonary embolus with no known predisposing factor is seen for a routine outpatient visit; she is found to have an international normalized ratio (INR) of 3.5. There has been no recent change in her other medications. On physical examination, there is no evidence of bruising or bleeding. 1. Which of the following is the most reasonable approach to managing the patient’s elevated INR? Administer 3 to 5 mg of vitamin K1 orally to lower the INR Stop warfarin therapy and administer 1 mg of vitamin K1 subcutaneously to lower the INR Stop warfarin therapy and administer 2 units of fresh frozen plasma to lower the INR Stop warfarin therapy and do not resume, because 3 months is long enough to treat a pulmonary embolism Stop warfarin therapy temporarily and recheck the INR every 1 to 2 days Click here to compare your answer. 2. The resident assigned to the case decides to evaluate the pulmonary embolus further by looking for a hypercoagulable state (ie, an increased predisposition to clotting). The work-up reveals the following results: protein C activity, 22% (normal, > 60%); protein S activity, 24% (normal, > 60%); factor V Leiden gene rearrangement test, mutation not detected; prothrombin 20210 gene rearrangement test, mutation not detected. Based on these results, which of the following best describes the patient’s condition? The patient has protein C deficiency The patient has protein S deficiency The patient has both protein C and protein S deficiency The patient has factor V Leiden deficiency There is no evidence of a hypercoagulable state Click here to compare your answer.		3. A 37-year-old woman sees her physician because of calf pain; ultrasonography reveals a deep vein thrombosis in the calf. Which of the following is the most appropriate step in the initial management of her condition? Administer a low-molecular-weight heparin (LMWH) (eg, enoxaparin 1.0 mg/kg body weight twice daily) along with a 40-mg loading dose of warfarin, followed by warfarin 5.0 to 7.5 mg daily Administer a LMWH (eg, enoxaparin 1.0 mg/kg twice daily) along with a 20-mg loading dose of warfarin, followed by warfarin 5.0 to 7.5 mg daily Administer a LMWH (eg, enoxaparin 1.0 mg/kg twice daily) along with warfarin 5.0 to 7.5 mg daily Start unfractionated heparin therapy at a bolus dose of 80 U/kg followed by 18 U/kg per hour, and then adjust based on the patient’s partial thromboplastin time Start warfarin therapy alone at a dose of 5.0 to 7.5 mg daily Click here to compare your answer. 4. The most appropriate treatment of heparin-induced thrombocytopenia with thrombosis in a patient receiving therapy with unfractionated heparin is to stop administering unfractionated heparin and perform which of the following steps? Start LMWH therapy Start therapy with lepirudin, argatroban, or danaparoid Start tissue plasminogen activator therapy Start warfarin therapy Wait for platelets to recover Click here to compare your answer.
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