anticoagulation

Practice targeted AMC-style multiple-choice questions on anticoagulation.

Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 72-year-old female presents with right leg pain and skin changes after starting warfarin for atrial fibrillation. Her INR is 3.5. Examination reveals the findings in the image. What is the MOST appropriate next step in management?

A. Administer vitamin K and discontinue warfarin

B. Elevate the leg and apply compression bandages

C. Prescribe a broad-spectrum antibiotic

D. Apply topical corticosteroids

E. Increase the dose of warfarin

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 78-year-old female on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of increasing pain and discolouration in her right lower leg. She reports the pain is severe and worsening rapidly. She denies trauma or recent falls. Her INR this morning was 2.5 (target 2.0-3.0). Vital signs are stable: BP 130/80, HR 75, RR 16, Temp 36.8°C. Examination reveals the findings shown in the image. Considering the patient's history, current medication, and the clinical appearance depicted, what is the most appropriate immediate therapeutic intervention?

A. Discontinue warfarin and administer Vitamin K.

B. Arrange urgent surgical debridement of the affected area.

C. Initiate broad-spectrum intravenous antibiotics.

D. Increase warfarin dose to achieve an INR of 3.0-4.0.

E. Prescribe oral analgesia and arrange outpatient follow-up.

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CT scan showing hemothorax caused by warfarin use

Image by Cevik Y — CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents with acute dyspnea and pleuritic chest pain. His INR is 7.0. A chest CT is performed (image attached). After initial resuscitation, what is the MOST appropriate intervention?

A. Administer intravenous vitamin K and prothrombin complex concentrate

B. Perform needle thoracostomy

C. Administer intravenous protamine sulfate

D. Administer intravenous furosemide

E. Observe and repeat CT scan in 6 hours

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Image by Cevik Y — CC BY 3.0 · Source

A 78-year-old male on warfarin presents with dyspnea and pleuritic chest pain after a fall. INR is 7.0. A chest CT is performed (image attached). After initial resuscitation, what is the MOST appropriate next step?

A. Observe and repeat CT chest in 6 hours

B. Administer intravenous vitamin K and prothrombin complex concentrate

C. Perform bronchoscopy with bronchoalveolar lavage

D. Administer intravenous protamine sulfate

E. Insert an intercostal chest drain

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Image by Cevik Y — CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents with sudden onset of severe dyspnoea and right-sided pleuritic chest pain. He denies trauma. On examination, he is tachypnoeic, oxygen saturation is 92% on room air. Blood pressure 110/70 mmHg, heart rate 95 bpm. Chest examination reveals decreased breath sounds on the right. A CT scan of the chest is performed. Considering the patient's clinical presentation, medical history, and the findings demonstrated in the provided image, which of the following pharmacological agents is the most appropriate immediate intervention?

A. Fresh frozen plasma (FFP)

B. Vitamin K

C. Tranexamic acid

D. Prothrombinex (PCC)

E. Recombinant Factor VIIa

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 68-year-old female presents with right leg pain and skin changes after starting warfarin for atrial fibrillation 5 days ago. Her INR is currently 3.5. Examination reveals the findings in the image. What is the MOST appropriate next step in management?

A. Apply compression bandages and elevate the leg

B. Start heparin and continue warfarin at the same dose

C. Reduce warfarin dose and monitor INR daily

D. Stop warfarin and administer vitamin K and fresh frozen plasma

E. Continue warfarin at the same dose and apply topical corticosteroids

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Image by Cevik Y — CC BY 3.0 · Source

A 78-year-old male on warfarin presents to the ED after a fall. He complains of dyspnea and right-sided chest pain. His INR is 5.0. Vitals: HR 110, BP 100/60, RR 28, SpO2 90% on room air. The provided image was obtained. What is the MOST appropriate next step?

A. Administer IV protamine sulfate

B. Tube thoracostomy

C. Administer IV vitamin K

D. Administer IV tranexamic acid

E. Observation with serial chest X-rays

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A 78-year-old man with a history of chronic atrial fibrillation and hypertension presents to the emergency department with sudden onset of severe pain, numbness, and coldness in his left leg, starting approximately 3 hours ago. He is currently taking aspirin 100mg daily. On examination, his left foot and lower calf are pale and cool to touch. Pedal pulses are absent, popliteal pulse is weak. Sensation is decreased below the ankle, and motor function is preserved but weak. Capillary refill in the toes is delayed. His heart rate is irregularly irregular at 95 bpm, blood pressure 140/85 mmHg. What is the most appropriate initial management step?

A. Initiate intravenous unfractionated heparin and consult vascular surgery urgently.

B. Administer a bolus of intravenous fluid and analgesia.

C. Start a continuous infusion of alteplase.

D. Order an urgent CT angiography of the left lower limb.

E. Arrange for an urgent venous duplex ultrasound to rule out deep vein thrombosis.

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Image by Cevik Y — CC BY 3.0 · Source

A 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He has a history of atrial fibrillation and has been taking warfarin for the past 5 years. His INR is currently 6.0. A CT scan of the chest is performed (image attached). What is the MOST appropriate initial management step?

A. Administer intravenous vitamin K and prothrombin complex concentrate (PCC)

B. Administer intravenous tranexamic acid

C. Administer intravenous protamine sulfate

D. Perform a needle thoracostomy

E. Observe and monitor the patient's respiratory status

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Image by Cevik Y — CC BY 3.0 · Source

A 68-year-old male on warfarin presents post-fall with dyspnea and pleuritic chest pain. INR is 4.8. Vitals: HR 115, BP 95/60, RR 26, SpO2 89% on air. The provided image was obtained. What is the MOST appropriate next step?

A. Perform needle thoracostomy

B. Order a V/Q scan

C. Administer vitamin K

D. Insert a chest tube

E. Administer IV fluids and observe

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A 68-year-old man with atrial fibrillation is scheduled for elective hip replacement surgery. He is currently on warfarin with a target INR of 2.0-3.0. His INR is 2.5 at the preoperative assessment. What is the most appropriate management of his anticoagulation therapy in preparation for surgery?

A. Stop warfarin 2 days before surgery and start a direct oral anticoagulant (DOAC) instead

B. Continue warfarin and adjust the dose to achieve an INR of less than 1.5 before surgery

C. Stop warfarin 5 days before surgery and consider bridging with low molecular weight heparin (LMWH) if high thromboembolic risk

D. Switch from warfarin to aspirin 7 days before surgery

E. Stop warfarin 1 day before surgery and resume it immediately after the procedure

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 65-year-old patient recently started on warfarin for deep vein thrombosis presents with a painful, expanding skin lesion on their leg. They report the lesion appeared suddenly and has worsened over the past 24 hours. INR is 2.8. Considering the clinical presentation and the appearance of the lesion, what is the most appropriate immediate management step?

A. Apply topical corticosteroids and compression bandaging.

B. Administer broad-spectrum antibiotics and debride the lesion.

C. Obtain a tissue biopsy for histopathology and culture.

D. Stop warfarin and initiate heparin and vitamin K.

E. Increase the warfarin dose and monitor INR closely.

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Image by Cevik Y — CC BY 3.0 · Source

A 68-year-old male on warfarin presents with pleuritic chest pain and mild dyspnea. INR is 4.5. The image was obtained. What is the MOST appropriate initial intervention?

A. Observation and serial chest X-rays

B. Urgent bronchoscopy

C. Vitamin K administration

D. Chest tube insertion

E. IV protamine sulfate

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Image by Cevik Y — CC BY 3.0 · Source

A 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He reports a recent fall but denies any significant trauma. He has a history of atrial fibrillation and is currently taking warfarin. His INR is 6.5. A CT scan of the chest is performed (image attached). What is the MOST appropriate immediate next step in management?

A. Observe and repeat INR in 6 hours

B. Administer intravenous vitamin K and prothrombin complex concentrate (PCC)

C. Perform a needle thoracostomy

D. Administer intravenous protamine sulfate

E. Administer intravenous heparin

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A patient on warfarin presents with leg pain. INR is 3.5. Given the image, what is the MOST appropriate next step?

A. Stop warfarin and administer vitamin K

B. Elevate the leg and apply warm compresses

C. Continue warfarin at the same dose

D. Apply topical corticosteroids

E. Start heparin and continue warfarin

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

An 82-year-old woman with a history of paroxysmal atrial fibrillation and a recent hospitalisation for pneumonia was discharged 5 days ago on warfarin 5mg daily. She presents to the emergency department complaining of increasing pain and a rapidly evolving lesion on her right lower leg over the past 48 hours. She denies trauma. Her vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, Temp 36.8°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Her INR today is 4.5. She has no known history of protein C or S deficiency. Considering the patient's history, current medication, laboratory result, and the clinical appearance depicted, which of the following represents the most appropriate immediate management strategy?

A. Prescribe oral flucloxacillin and review in 24 hours for suspected bacterial cellulitis.

B. Increase the daily dose of warfarin to achieve a target INR of 2.5-3.0 more rapidly.

C. Arrange for urgent surgical consultation for debridement of the necrotic tissue.

D. Discontinue warfarin, administer intravenous vitamin K, and initiate therapeutic dose unfractionated heparin or low molecular weight heparin.

E. Switch warfarin to rivaroxaban 20mg daily and monitor the lesion.

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 78-year-old female on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of increasing pain and discolouration in her right lower leg. She denies trauma or recent falls. Her INR this morning was 2.5 (target 2.0-3.0). Vital signs are stable: BP 130/80, HR 75, RR 16, Temp 36.8°C. Examination reveals the findings shown in the image. Considering the patient's history, current medication, and the clinical appearance depicted, what is the most appropriate immediate management?

A. Discontinue warfarin, administer Vitamin K, and initiate heparin or LMWH.

B. Arrange urgent surgical debridement of the affected area.

C. Increase the dose of warfarin and monitor INR closely.

D. Initiate broad-spectrum intravenous antibiotics.

E. Perform a Doppler ultrasound of the leg veins.

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 68-year-old woman recently started on warfarin for a pulmonary embolism presents with a painful, rapidly expanding purpuric lesion on her thigh, which developed two days ago. Her INR is 2.5. She has no history of trauma to the area. Considering the clinical presentation and the appearance of the lesion, what is the most likely underlying pathophysiological process?

A. Allergic vasculitis secondary to warfarin

B. Protein C deficiency leading to paradoxical thrombosis

C. Vitamin K deficiency exacerbating bleeding

D. Direct toxic effect of warfarin on dermal capillaries

E. Heparin-induced thrombocytopenia causing microthrombi

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A 70-80 year old lady being treated for pulmonary embolism with a therapeutic dose of subcutaneous Enoxaparin is found to have multiple new pulmonary emboli. What is the most appropriate next step?

A. Start streptokinase infusion.

B. Switch to intravenous unfractionated heparin.

C. Switch to oral warfarin.

D. Increase the dose of subcutaneous enoxaparin.

E. Insert an IVC filter.

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A patient on warfarin presents with leg pain. INR is 3.5. Given the image, what is the MOST likely underlying cause?

A. Antithrombin III deficiency

B. Factor V Leiden mutation

C. Protein C deficiency

D. Protein S deficiency

E. Prothrombin G20210A mutation

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A 34-year-old man presents to the Emergency Department with acute-onset shortness of breath. A CT pulmonary angiogram (CTPA) is ordered, shown in the photograph, confirming a diagnosis of pulmonary embolism. Which of the following is the most appropriate initial treatment option for this patient?

A. Thrombolytic therapy.

B. Caval filter.

C. Unfractionated heparin or low-molecular weight heparin (LMWH).

D. Dabigatran.

E. Warfarin.

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A 70-80 year old lady, currently managed for pulmonary embolism with Enoxaparin 40 mg daily, is found to have multiple pulmonary emboli. Her vitals are within normal limits. What would be the most appropriate next step?

A. Insert an IVC filter.

B. Switch to apixaban.

C. Switch to oral warfarin.

D. Increase Enoxaparin to therapeutic dose.

E. Start streptokinase infusion.

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 72-year-old woman presents with increasing pain in her right leg. She has been on warfarin for atrial fibrillation for the past 5 days. Her INR is currently 3.5. Examination reveals the findings shown. What is the MOST appropriate next step in management?

A. Prescribe oral antibiotics

B. Apply topical corticosteroids

C. Stop warfarin and administer vitamin K

D. Continue warfarin at the same dose

E. Start intravenous heparin

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Image by Cevik Y — CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents to the emergency department with sudden onset of severe dyspnoea and right-sided pleuritic chest pain. He denies trauma. On examination, he is tachypnoeic, oxygen saturation is 92% on room air. Blood pressure 110/70 mmHg, heart rate 95 bpm. Chest examination reveals decreased breath sounds on the right. A CT scan of the chest is performed. Considering the patient's clinical presentation, medical history, and the findings demonstrated in the provided image, which of the following interventions is most critical to initiate *before* considering invasive drainage?

A. Insertion of a large-bore chest tube

B. Urgent surgical exploration of the chest

C. Administration of prothrombin complex concentrate (PCC) or Factor IX complex

D. Initiation of therapeutic heparin infusion

E. Intravenous administration of broad-spectrum antibiotics

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Image by Cevik Y — CC BY 3.0 · Source

A 72-year-old male on warfarin presents with sudden onset shortness of breath and right-sided chest pain after a fall. His INR is 4.5. The provided image was obtained. What is the MOST appropriate next step in management?

A. Administration of intravenous vitamin K

B. Bronchoscopy to rule out airway obstruction

C. Observation with serial chest X-rays

D. Administration of prothrombin complex concentrate

E. Insertion of an intercostal chest drain

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A patient on warfarin presents with leg pain. INR is 3.5. Given the image, what is the MOST appropriate initial pharmacological intervention?

A. Vitamin K and four-factor prothrombin complex concentrate (PCC)

B. Topical corticosteroids

C. Low molecular weight heparin (LMWH)

D. Intravenous antibiotics

E. Continue warfarin at the same dose

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Image by Cevik Y — CC BY 3.0 · Source

A 68-year-old male presents to the emergency department complaining of acute onset shortness of breath and right-sided chest pain. He reports that the pain started suddenly this morning and has been gradually worsening. He has a history of paroxysmal atrial fibrillation, for which he takes warfarin. He denies any recent trauma or injury. On examination, his vital signs are: heart rate 115 bpm, blood pressure 95/60 mmHg, respiratory rate 30 breaths per minute, oxygen saturation 87% on room air. Auscultation reveals decreased breath sounds on the right side. The patient appears pale and is diaphoretic. His INR is 6.5. A CT scan of the chest is performed, and the relevant image is shown. What is the MOST appropriate next step in the management of this patient?

A. Perform needle thoracostomy followed by insertion of an underwater seal drain

B. Administer intravenous protamine sulfate and monitor for improvement in respiratory status

C. Administer intravenous furosemide and monitor urine output

D. Insert a chest tube and administer intravenous vitamin K and prothrombin complex concentrate (PCC)

E. Administer intravenous antibiotics and schedule a repeat CT scan in 24 hours

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Image by Cevik Y — CC BY 3.0 · Source

A 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He has a history of atrial fibrillation and has been taking warfarin for the past 5 years. His INR is currently 6.5. A CT scan of the chest is performed (image attached). What is the MOST appropriate immediate next step in the management of this patient?

A. Insert an intercostal chest drain

B. Administer intravenous vitamin K and prothrombin complex concentrate (PCC)

C. Perform a diagnostic thoracentesis

D. Observe and repeat INR in 6 hours

E. Administer intravenous protamine sulfate

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 68-year-old patient on warfarin for a recent DVT presents with a painful, rapidly expanding skin lesion on their leg that started 48 hours ago. Their INR is 2.9. Given the clinical context and the appearance of the lesion, what is the most appropriate immediate management step?

A. Increase the warfarin dose and monitor INR closely.

B. Switch warfarin to a direct oral anticoagulant (DOAC).

C. Obtain a skin biopsy and continue current management.

D. Apply topical antibiotics and continue warfarin.

E. Stop warfarin, administer Vitamin K, and initiate heparin.

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 68-year-old woman on warfarin for chronic atrial fibrillation presents with increasing pain in her right leg over the past 48 hours. Her INR is 4.0. Examination reveals the findings in the image. What is the MOST likely underlying cause?

A. Protein S deficiency

B. Prothrombin gene mutation

C. Antithrombin III deficiency

D. Factor V Leiden mutation

E. Protein C deficiency

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A. Increase the dose of warfarin to achieve a higher INR

B. Start intravenous heparin and continue warfarin

C. Apply compression bandages and elevate the leg

D. Continue warfarin at the same dose and apply topical corticosteroids

E. Stop warfarin, administer vitamin K and start a direct oral anticoagulant

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A. Administer subcutaneous low molecular weight heparin and continue warfarin.

B. Initiate broad-spectrum antibiotics and arrange for surgical debridement.

C. Reduce the dose of warfarin and monitor the lesion closely.

D. Administer fresh frozen plasma to correct the INR and continue warfarin at a lower dose.

E. Stop warfarin, administer intravenous Vitamin K, and initiate therapeutic dose unfractionated heparin.

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Image by Cevik Y — CC BY 3.0 · Source

A 75-year-old male on warfarin for atrial fibrillation presents with acute dyspnoea and pleuritic chest pain. He is hypotensive with a BP of 90/60 mmHg and tachycardic at 110 bpm. His INR is 7.2. A chest CT is performed (image attached). Considering the clinical context and imaging findings, what is the MOST appropriate immediate management step?

A. Administer intravenous Vitamin K and Prothrombinex-VF

B. Initiate high-flow nasal cannula oxygen

C. Arrange for urgent surgical consultation for thoracotomy

D. Perform urgent tube thoracostomy

E. Administer intravenous furosemide

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Image by Cevik Y — CC BY 3.0 · Source

A 78-year-old male on warfarin presents with acute shortness of breath. INR is 5.0. The provided image was obtained. What is the MOST likely underlying cause?

A. Pneumonia

B. Anticoagulation-related bleeding

C. Heart failure exacerbation

D. Pulmonary embolism

E. Spontaneous pneumothorax

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Image by Cevik Y — CC BY 3.0 · Source

A 72-year-old male on warfarin presents with sudden onset dyspnea. His INR is 6.0. The provided image was obtained. What is the MOST appropriate next step?

A. Administer IV vitamin K and prothrombin complex concentrate

B. Observe and repeat imaging in 24 hours

C. Perform needle thoracostomy

D. Administer IV protamine sulfate

E. Administer IV furosemide

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A 62-year-old woman presents to the emergency department with acute confusion and weakness on the right side of her body. She has a history of atrial fibrillation and is on warfarin for anticoagulation. Her INR is 3.5. On examination, she is disoriented to time and place, with a right-sided facial droop and hemiparesis. A CT scan of the head shows a left-sided intracerebral hemorrhage. What is the most appropriate next step in the management of this patient?

A. Start intravenous heparin

B. Administer intravenous vitamin K and prothrombin complex concentrate

C. Initiate oral antihypertensive therapy

D. Administer intravenous mannitol

E. Perform an urgent neurosurgical intervention

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 75-year-old woman on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of rapidly worsening pain and discolouration in her right lower leg. She denies trauma. Her INR is 2.8. Physical examination reveals the findings shown in the image. Peripheral pulses are palpable. What is the most appropriate immediate management step?

A. Perform urgent surgical debridement of the affected area

B. Order a Doppler ultrasound of the leg to rule out deep vein thrombosis

C. Stop warfarin and administer Vitamin K and heparin

D. Increase the dose of warfarin to achieve a higher INR

E. Administer broad-spectrum intravenous antibiotics for suspected cellulitis

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anticoagulation

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