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Case studies on coagulation.

Guidelines:

1. This is a group activity. Any members of the group who will not participate should not be
included on the names to be submitted in the final report.
2. Format of the presentation:
a. The presentation should be in powerpoint with narration or discussion coming from the
group.
b. Each section is given 7 sets of cases. It is in the discretion of the class on how to select a
case per group.
c. Each group should come up with a creative and related title to the case.
d. The case needs to be stated first before answering the question.
e. The answers should be clear, brief and concise. The correct answer will be e-mailed to
you after all the groups have submitted their output.
f. Length of presentation: no greater than 7 minutes.
3. Do not plagiarize, always write the references used in answering the questions. Use APA style
for citations and add bibliography at the end using the aforementioned citation formatting.
4. Deadline for submission: September 30, 2017, 11:59PM. Submission is through my e-mail,
gjpaz@feu.edu.ph. Submission is per group, write in the subject of the email: SECTION NUMBER
GROUP NUMBER (Example: SECTION 0 GROUP 0). This is also how you will name the file that you
will submit. If the file is too large, a link may be sent through the e-mail as well.
5. The grading of the presentation will be based on the rubrics included in this file.
6. Some of the reference values are given in the case, however, if the reference values are not
given, please refer to the reference value in Rodak’s hematology book (cover page).
7. For any questions or clarifications, message me through the e-mail I sent or through my
facebook messenger.

Case 1.

A small group of physicians, laboratory scientists, and nurses set up a clinic in a developing country
plagued by famine. In one particular village, the group noticed that many of the children and adults
had bleeding gums and petechiae on the buttocks. A few of the children had hemorrhagic areas
below their eyes.

1. What is the most likely cause of these abnormal physical findings?


2. What is the name of this disorder, and how does it affect the vascular system?
3. What is the easiest and most cost-effective diagnostic approach when this disorder is
suspected?
4. With successful treatment, what are the effects on abnormal laboratory findings and patient
physical findings relating to this disorder?

Case 2.

A 9-year old black girl with a markedly prolonged PTT (58.0 sec, control 28.0) was referred to a
hematologist for evaluation of her coagulation abnormality in preparation for a dental extraction.
The patient’s PT (11.4 sec, control 11.3) and bleeding time (6.5 min., normal 2-7) were normal. She
had undergone an appendectomy at 2 years of age without any bleeding complications. There was
no family history of a bleeding disorder on the paternal side; however, no information was available
on the maternal side.

1. Which of the classic coagulation systems appears to be affected in this case? Why?
2. What coagulation factors could be deficient?
3. Given her abnormal PTT, is it surprising that she had no bleeding problems associated with her
appendectomy? Explain.
4. What coagulation factors are more likely to be deficient given that this child does not appear
to have bleeding problems?
5. What coagulation tests might be recommended to evaluate this child’s abnormal PTT?
6. Would she be expected to have bleeding complications from a dental extraction?
Case 3.

A coagulation panel was ordered on a 64-year old man before coronary bypass surgery. The
surgeon was concerned about an abnormal PTT result. The patient had a negative history of any
bleeding or bruising tendency and denied any family history of bleeding disorders. The laboratory
parameters on this patient were as follows: WBC 7.8x10^9/L; RBC 6.92x10^12/L; Hb 20.4g/dL; Hct 0.62
L/L; PLT: 335x10^9/L; PT 11.2 seconds; INR 1.05; PTT 58.4 seconds.

1. In addition to the elevated PTT, other test parameters in this panel are abnormal. What are
they?
2. What steps should be taken to evaluate the abnormal PTT?
3. In light of the abnormalities, what is the probable cause of the spurious abnormal PTT in this
patient?

Case 4

A 35-year old female was referred to a hematologist for the evaluation of an abnormal PTT. All other
laboratory tests, including WBC, RBC, Hb, Hct, PLT, PT, fibrinogen and bleeding time were all within
reference ranges. The patient had a negative history for bleeding or bruising problems. The original
PTT was 72.4 seconds; a repeat PTT was 69.8 seconds (done in different laboratory).

1. Is a spuriously abnormal PTT suggested here?


2. What test(s) should be done to evaluate this abnormality?
3. What additional test(s) could be used to evaluate this patient?

Case 5

A 12 year old white male was seen for evaluation of frequent epistaxis and ecchymoses. Pertinent
history revealed hematuria at 3 years of age without evidence of renal disease. Microhematuria was
a consistent feature on urinalysis reports. Adenoidectomy at 5 years of age resulted in exaggerated
hemorrhage that necessitated packing of the nasal passages. A knee injury at 7 years of age
required hospitalization to manage the hemarthrosis. Loss of primary teeth resulted in exaggerated
bleeding. To date, the patient has not received any transfused components as therapy. He is an only
child; no other positive history exists in the family.

The laboratory data (with reference ranges) were as follows: PTT 68 seconds (22-36 seconds);
correction of PTT with adsorbed plasma was obtained; PT 10.5 seconds (10.3-12.5 seconds, ISI 2.0);
Simplate bleeding time 17 minutes (3-9.5 minutes); PLT 289x10^9/L (150-450x10^9/L); factor VIIIC:Ag
assay 11% (54-195%); von willebrand factor antigen (vWF:Ag) 30% (50-150%); vWF multimer pattern,
only small multimers present; von willebrand ristocetin cofactor (vWF:RCoF) 5% (50-150%).

1. What common denominator is evident in this patient’s history? Of what significance is the
family history?
2. This patient was diagnosed with Von Willebrand Disease. What laboratory data support this
diagnosis?
3. What is the significance of the results of vWF multimer pattern in this case? What is the type
classification of this patient’s disorder?

Case 6.

A 36-year-old black woman was admitted through the emergency room with chief complaints of
headache, dizziness, lethargy, nausea, vomiting, and weakness. Three months earlier, she underwent
a subtotal gastrectomy for adenocarcinoma of the stomach. She was placed on mitomycin therapy,
a cancer chemotherapeutic drug. Diagnostic procedures indicated a recurrence of the carcinoma.

Laboratory testing revealed a moderately increased leukocyte count with a neutrophilia and a
normocytic, normochromic anemia with marked anisocytosis and red cell fragmentation. There were
3 nucleated RBC per 100 leukocytes. Repeated manual platelet counts ranged from 10-50x10^9/L
except for brief increases following platelet transfusions. The PTT and fibrinogen assays remained
within normal limits throughout most of the patient’s hospitalization. The PT was slightly prolonged (13-
17 seconds; reference range was 10.5-13.0 seconds) until her death from respiratory failure on day 19.
Urinalysis revealed increased protein, 60-100 RBC per high power field, and granular and hyaline
casts. Serum chemistries showed increased LD, creatinine, and BUN and decreased haptoglobin.

1. Why was the patient’s platelet count monitored by manual rather than automated methods?
2. What are the possible diagnoses and why?
3. What may have triggered the acute onset?
4. What other laboratory data may be of value in determining the pathogenesis of the
thrombocytopenia?

Case 7.

A 6-year old boy had repeated nosebleeds and a tendency to bruise. This concerned his aunt, a
clinical laboratory scientist. She examined a blood film made from a capillary skin puncture sample
and noted that the platelet count appeared normal but that, contrary to the expectation with a
capillary puncture sample, his platelets were not clumped on the blood film. She persuaded her sister
to take the boy to a physician. The patient’s CBC was normal but his bleeding time exceeded 15
minutes. The PT, PTT, thrombin time, and fibrinogen assay were all normal. Platelet aggregation
studies revealed a total lack of response to ADP, a partial response to collagen, and a normal
response to ristocetin.

1. What is a likely cause for the patient’s bleeding history and what other laboratory tests might
be helpful?
2. What is the basic defect in this condition?
3. What information was obtained by the original capillary puncture blood film?

Rubrics

SECTION ________________ GROUP NUMBER __________


Criteria 5 4 3 2 1
1. Formatting
2. Organization
3. Length of presentation
4. Clarity
5. Creativity of the title
6. Overall creativity
7. Nearness to the expected
answer. (Double points)
8. Completeness of the answer.
(Double points)
9. Appropriateness of the answer
10. Manner of answering and
delivery.
11. Grammatical errors
12. File labelling
13. Submission
Other deductions/comments: Total Score:

* Double points: scores on these criteria is multiplied to 2 (example: 5 x 2 = 10)