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Review Question - QID 109635

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QID 109635 (Type "109635" in App Search)
A 37-year-old previously healthy woman presents to the emergency room with right leg pain and difficulty breathing. She recently returned from a trip to Alaska and noticed her leg started to swell when she got home. Her medications include a multivitamin and oral contraceptives. She is diagnosed with a deep venous thrombosis complicated by a pulmonary embolism and started on anticoagulation. She remains stable and is discharged on the third hospital day with long-term anticoagulation. During the 2 month follow-up visit, the patient’s lab results are as follows:

Hemoglobin: 14 g/dL
Hematocrit: 44%
Leukocyte count: 5,000/mm^3 with normal differential
Platelet count: 300,000/mm^3
Prothrombin time: 23 seconds
Partial thromboplastin time (activated): 20 seconds
Bleeding time: 4 minutes

Which of the following factors is initially involved in the target pathway for her long-term treatment?

II

9%

22/233

V

14%

33/233

VII

55%

128/233

IX

4%

9/233

X

13%

31/233

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This patient is being treated with warfarin due to a recent pulmonary embolism. Factor VII is the first factor involved in the extrinsic pathway of the coagulation cascade.

Warfarin inhibits the factors in the extrinsic pathway of the coagulation cascade. The extrinsic factors include II, VII, IX, and X. The initial factor activated is factor VII, which binds to tissue factor released by damaged tissue. The first factors that warfarin inhibits are protein C and factor VII. Heparin is used in addition to warfarin for the first few days of treatment due to the transient hypercoagulable state that occurs as a result of the shorter half-life of protein C and protein S. Patients with warfarin will have an elevated PT with normal PTT and bleeding time.

Incorrect Answers:
Answer 1: Factor II, prothrombin, is cleaved to thrombin following activation of factor V. It is inhibited by warfarin.

Answer 2: Factor V is not affected by warfarin.

Answer 4: Factor IX deficiency is seen in hemophilia B. It is also part of the intrinsic pathway inhibited by warfarin but is not the initial factor.

Answer 5: Factor X is part of the extrinsic pathway but is not the initial factor of the pathway.

Bullet Summary:
Factor VII is the initial factor activated in the extrinsic coagulation cascade.

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