Neoplasm at the Head of the Pancreas: A Case Study

CASE PRESENTATION A 68-year-old male was seen by his anticoagulation clinic doctor for a scheduled warfarin check up. He had been diagnosed with deep vein thrombosis (DVT) about two years ago. The patient's international normalized ratio (INR) was 6.31; his target range is 2.0 to 3.0. The patient was referred to the evaluation clinic, where he was administered 2.5 mg of vitamin K. Consideration was given to his initial complaints of stomach ailments at the start of fluctuating INRs in the following weeks (Table 1).

In addition to unintentional weight loss, physician examination revealed that the patient claimed episodes of hematuria. He also complained of recent lower back and stomach pain, and for the past four weeks, blood-tinged sputum in the mornings. The patient has a history of smoking.

A urinalysis was performed and was negative for blood. Upon palpitation, his abdomen was non-tender and without masses. A 48-hour follow-up appointment was made with the anticoagulation clinic.

On the second day, the patient's prothrombin time (PT) was redrawn, and demonstrated an INR of 4.29. He maintained his directed warfarin dosage and was scheduled to return in 12 days.

At 14 days he displayed a critical INR of 6.58 and was administered another 2.5 mg of vitamin K. However, at this appointment, the patient confessed missing a warfarin dose within the last ten days. Plans were documented to decrease his warfarin dosage when the patient's INR fell to within his target range. His next appointment was scheduled for two days later.

ABBREVIATIONS: DVT = deep vein thrombosis; ERCP = endoscopic retrograde cholangiopancreatography; INR = international normalized ratio; PTCA = percutaneous transhepatic cholangiogram.