Asignacion # 4 Casos de Estudio desordenes hemorragicos

Caso # 1

 A un niño de 12 años se le extraen dos molares en preparación para ortodoncia y en el

procedimiento sufre de una hemorragia persistente. Existe historial familiar de hematomas y
epistaxis frecuente, particularmente su mama que incluso padece de menorragia. El examen
fisico revela varios echymoses en las extremidades inferiores.

Laboratory findings:

test results Ref value

PT 12.0 secs 10-14

APTT 40 secs 23-36

BT >15 mins 2-9

Platelet count 300,000/ul 15-450 x109/L

F VIII:C 30% 50-150%

vWF:Ag 45% 50-150%

vWFR:Co 41% 50-150%

RIPA Depressed response Normal response

Multimers Normal Normal

 Which is the possible diagnosis?

 Which laboratory values reflect a type I von Willebrand disease?

 What form of therapy would be indicated?

Caso # 2

 A full term male baby was born by normal delivery. 36 hours later he is still bleeding
intermittently at the umbilical cord.

 Laboratory results

Test Results Ref value

CBC & platelet ct normal normal

PT 14.0 secs 10-14

APTT 36 secs 23-36

Fibrinogen 400 mg/dl 200-400

 What additional test is necessary to diagnose this case?

 Which of the patient case description correlate with the possible diagnosis?

 Possible diagnosis??
Case # 3

 A 5 year old presented in the ER with a hemarthrosis of the right knee after falling off a
playground swing. No other abnormal physical findings were observed.

 Laboratory results

Test results Ref values

CBC & PLts Normal Normal

PT 13.0 secs 10-14

APTT 87 secs 23-36

Fibrinogen 325 mg/dl 200-400

BT 6 mins 2-9

APTT 1:1mix 32 secs 23-36

F VIII:C 10% 50-150

vWF:Ag 90% 50-150

 Which is the possible diagnosis?

 Which material was used to make the mix with the patient plasma in order to detect the
possible deficiency?

 Why did the bleeding time remains within the reference values?

 Treatment indicated for this patient.

 What additional information does the physician need to know about this patient history?
Caso # 4

 A 25 year old man was admitted for hernia repair.

 Screening laboratory results

Test Result Ref value

CBC & Plts Normal Normal

PT 12.5 secs 10-14

APTT 115 secs 23-36

Test Results Ref value

APTT mixing studies 25 secs 23-36

VIII:C 95% 50-150

IX 104% 50-150

XI 110% 70-130

XII 96% 70-140

 Interval incubations of the patient plasma with the APTT produced the following results

Test Result Ref value

5 Min incubation 115 secs 23-36

10 Min incubation 57 secs 23-36

15 Min incubation 35 secs 23-36

 Why is the APTT abnormal and PT normal?

 Why the APTT is corrected with incubation??

 What is the possible deficiency?

 What treatment would be indicated?

Caso # 5

 A 32 year old white woman in her 36 weeks of gestation came to the ER with profuse vaginal
bleeding. Large ecchymosys and continue oozing from venipuncture sites were evident. No
family bleeding history.

Test result Ref value

PT 26 secs 11-13

APTT 84 secs 24-30

Platelet ct 20,000/ul 150-400

Fibrinogen 85 mg/dl 200-400

FDP >40mg/ml <10mg/ml

D-dimer positive negative

 What is the possible diagnosis?

 Which of the test results suggest this diagnosis?

 Which is the correlation with the patient clinical presentation and the possible disorder?

 What kind of treatment is use for this disorder?

 Caso #6

A 10-year-old Caucasian male is to undergo an elective tonsillectomy. The pre-operative history

describes significant bleeding after a recent tooth extraction. The mother reports that the bleeding
occurred several hours after the tooth extraction, after they had returned home from the dentist’s office

 Laboratory Test Results

Test Patient Normal Range

White blood cell count 6,000/μL 4,500 – 15,000/μL

Hemoglobin 14 g/dL 11.7 – 15.5 g/dL

Platelet count 250,000/μL 150,000 – 400,000/μL

Normal-appearing platelet morphology,

Peripheral smear evaluation no abnormal white blood cells, normal
shape and distribution of red blood cells

Prothrombin Time (PT) 13.5 sec 12.3 – 14.5 sec

Partial Thromboplastin Time (PTT) 50 sec 24 – 34 sec

PTT 1:1 mixing study 30 sec 24 – 34 sec

Ristocetin co-factor activity 85% 40% – 200%

von Willebrand antigen 75% 50% – 180%

 What is the possible diagnosis?

 Which of the test results suggest this diagnosis?

 Which is the correlation with the patient clinical presentation and the possible disorder? What kind of
treatment is use for this disorder?
Caso # 7

 PATIENT PRESENTATION

 A 64-year-old man who has not seen a doctor for 25 years presents to the emergency department after
four episodes of vomiting over the past two days. He describes the vomitus as looking like coffee grounds.

 For this patient the most important elements of the history are:

 Lack of abdominal discomfort, which makes gastritis or ulcer disease less likely

 Bruising, which can be suggestive of a coagulopathy

 Excessive alcohol intake, which can cause gastrointestinal bleeding

 No previous history of jaundice or liver disease

 III. LABORATORY DATA

 The patient’s coagulation test results:

 PT: 19 seconds with an INR of 2.7

 aPTT: 42 seconds.

 How could you work up these tests further?

1.Bleeding time or platelet function analysis

2. Mixing study

3. Platelet aggregation tests

Caso # 8

Evaluate the peripheral smear. Consider each of the following and select the
abnormalities that you identify in the peripheral smear

Which of the following are likely differential diagnoses for each problem on
this patient’s problem list? Consider each of the following and select on the
most likely options.

Select the appropriate cause related to the condition presented:

Coagulopathy

a..Liver disease Origin of anemia and gastrointestinal blood loss

b. Low platelets
c. Non-steroidal a.Esophageal
Anti-inflammatory
b.Gastritis
Liver disease
c.Peptic ulcer disease
a..Alcohol

b..Hepatitis C d. Spur cell hemolytic anemia

c. Abetalipoproteinemia