Case 1

Following surgery for a perforated duodenal ulcer, a 65 year old man developed
fever and confusion. On examination a few petechiae were seen on the legs and bruises
developed on his back. While taking his blood tests; blood oozed from venipuncture sites for
prolonged periods of time. His urine contained many organisms and white cells on smear.
No prior bleeding history was noted.

Investigations:
Hct 34%; WBC 25,000/ul with 70% neutrophils with toxic granulations and 20% bands
platelets 20,000/ul PT 19 sec, INR 2.3, aPTT 120 sec, TT 30 sec.

Questions:

1. Comment on the results of investigations?

2. What do we call this condition?
3. Describe the pathophysiology of this condition including the stages of hemostasis.
4. Describe the 2 pathways involved in the clot formation; at what clotting factor do
they converge?
5. Mention other laboratory test(S) which can be used to confirm the diagnosis?
6. What causes this condition in this patient?
7. Mention other possible causes for the condition?
8. What would be the principle therapy in this case?

Case 2

1
 A 12-year-old boy is sent to you for evaluation of a bleeding disorder. He has had
excessive bleeding after tonsillectomy and tooth extractions and also a history of bleeding
into his joints. The boy's maternal uncle had similar bleeding problems. The physical exam is
unremarkable. CBC, including platelet count is normal. PT 12 sec, (INR 1), aPTT 120 sec, &
bleeding time 6 min.

Questions:

1. What conclusions can be drawn from the results of the aPTT and PT?

2. What are the points in the history that give you clue to the diagnosis?

3. What is the diagnosis?

4. Where is the defect in this condition?

5. What are the management options?

Case 3
An 11-year-old girl is sent for evaluation for frequent nose bleeds. She has started
menstruating and her mother reports that the flow is very heavy. The patient's mother has
had similar bleeding problems. Except for a few bruises, the physical examination is
negative.

Hct 35%; WBC 7,000/ul; platelets 200,000/ul; PT 12 sec. INR 1; aPTT 100 sec.; Bleeding time
15 minutes.

Questions:

1- Comment on the lab results?

2- What clues from the history and lab results that points to the diagnosis?
3- What is the role of platelets in hemostasis?
4- What is the diagnosis?
5- Where is the defect in this condition?