This case involves a 53-year-old female patient who underwent mechanical mitral valve replacement and has been on long-term warfarin anticoagulant therapy, subsequently developed diffuse ecchymoses of the limbs and progressive both lower extremities swelling after she self-adjusted her warfarin dosage from 3 mg to 6 mg daily over 5 consecutive days. After admission, the patient's international normalized ratio was 12.71, and creatine kinase level was 1,989.47 U·L^-1, which led to the diagnosis of coagulopathy and rhabdomyolysis due to warfarin overdose. Following discontinuation of warfarin and initiation of fluid resuscitation therapy, the patient's creatine kinase levels returned to normal after 6 d. This case underscores the necessity of refining long-term warfarin management strategies and enhancing patient education to improve medication adherence and ensure both the efficacy and safety of anticoagulation therapy.

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