Clinical Case Questions Haemostasis And Thrombosis

Front 1

Case 1:

20 month year old boy

Refused to walk for past 2 days

Bleeding into joints

Which of these is the most likely?

Acute lympgoblastic leukaemia

Osteomyelitis

Von willerbramd Disease

Haemophilia

Back 1

Ans: Haemophilia

*cant be Von Willerbrands because it doesnt preset with bleeding into joints, more mucocutaneous bleeding (unless it is type 3 disease)*

Front 2

How do you differentiate between haemophilia A and B?

What tests would you run to confirm a diagnosis of Haemophilia?

Measure the APP

Measure the PT

Measure the factor VIII

Measure the platelet count

Back 2

Unlikely to be B, A is 5 times more common than B)

Ans: Measure the factor VIII

Front 3

How is heamophillia inherited?

Autosomal


Xlinked

Y linked

Autosomal dominant

Back 3

Ans: X-linked

Front 4

The father tells you the boys maternal grandfather has heamophillia A,

what are the chances of any further child having haemophilia A?

e.g wifes father had haemophilia A e.g normal man with carrier wife.

Back 4

1 in 4 chance of child having disease.

*The daughters of men with haemophilia are obligate carriers*

Front 5

What is the treatment of choice?

Recombinant Factor VIII

Fresh frozen plasma - not going to get enough of the factors in a high enough concentration.

DDAVP and tranexamic acid

Plasma derived factor VIII

Back 5

Ans: Recombinant Factor VIII - indépendant of blood donors so no infection risk

*not fresh frozen plasma because to won't get enough of the factors in a high enough concentration*

*not DDAVP and Tranexmic acid - not an option in severe heamophillia, seems to bind to the heamophullia cell and release VWF into the circulation so doesnt work for people who have no factor 8 becuase it isnt strong enough*

*not plasma derived factor VIII because it comes with a high risk of infection*

Front 6

Which of these is not a complication of planma derived therapy?


Hepatitis B

HIV

Hepatitis C

Hepatitis A

Back 6

Ans: Hep A - most rare v uncommon

Front 7

What is the other main complication of the treatment of heamopbhillia A with factor VII concentrates?

Development of antibodies

Allergic reactions - occasionally

Addiction to factor VIII

Increased risk of thrombosis

Back 7

Ans: Development of Antibodies - because the immune system has never seen factor 8 if you have severe haemophilia. If these antibodies develop then it will inhibit the factor 8 and make the treatment futile. 


Front 8

What is the best treatment regime for these patients?

Treat the patietns as soon as possible after bleed

Give factor VIII once a week

Give factor VIII at least 3 times a week

Bone marrow transplant

Back 8

Ans: Give factor VIII at least 3 times a week

*cant be give once a week because half life of factor VIII is too short and so would disappear*

*treating the patient soon after the bleed is all well and good but it isnt a long term solution*

Front 9

Case 2:

24 year old females student

Presents with 4 day historyy of easy bruising and small red spots on ankles

No previous history of bleeding after tonsilectomy and dental extraction.

Recently been off colour with flu.

On the combined oral pill.

What are the non-blanching spots on her arms?

Spider nevi

Brusises

Petechiae

Telangectasia

Back 9

Ans: Petechia (basically just small bruises)

*might be spider nevi - most common cause is oestrogen - so can be seen in those taking the combined pill*

Front 10

Which of these symptoms is she unlikely to have?

Mennorrhagia

Swollen, hot painful legs

Epistaxis

Buccal bleeding

Back 10

Ans: Swollen, hot painful legs

Front 11

What is the likely cause of her symptoms?

Thrombocytopenia

Scurvy

Vit K deficiency

Liver failure

Back 11

Ans: Thrombocytopenia

*liver failure can result in heamostatic failure (due to redced fibrinogenn and reduced platelet count)*

Front 12

Which of the following is not a cause of thrombocytopeniania?

Acute myeloid leukaemia


Vit K deficiency

Aplastic anaemia

ITP (idopahthaticy thrombocytepenic pupiura)

Back 12

Ans: Vit K deficiency - are, not the typical patter of bleeding - tend to see coagulation bleeding into head muscles, organs and joints

Front 13

The patient has spontaneous bruising and petechia formation, which platelet count is most likely?

Back 13

Answer is 10

*if platelet count is mild low then just bruising, if really low then they would be spontaneously bleeding*

Front 14

Which underlying illness is not associated with ITP? (autiomimune condition - breakdown of immune regulation which results in the removal of platelets from the circulation)

HIV 


Vit C deficiency (scurvy)

SLE

Glandular fever - often see ITP follow viral infection

Back 14

Ans: Vit C deficiency (scurvy) - presents with corkscrew hairs and abnormal gums

*SLE always associated with anything to do with auto immunity*

*Glandular fever - often see ITP follow viral infection*

Front 15

Case 3:

70 year old, excessive bleeding from colectomy He has bleeding from is adbomlas wound but not from his drain.

He has had surgery in the past but no abnormal bleeding.

What is the most likely cause?

Severe haemophilia A

Von willerbrands

LMWH prophylaxis

Poor surgical technique

Back 15

Ans: Poor surgical technique

*won't be heamophillia or von willerbrands because it would have been picked up before he reached this age*

*LMWH prophylaxis would have more systemic bleeding*

Front 16

Which of the following was NOT a reason the patient was given LMWH?

Surgery

Old age

Hypertension thromboembolism

Active cancer

Back 16

Ans: Hypertension - not a risk factor for VTE

Front 17

Case 4:

65 year old man takes aspirin for previous history of TIA.

How does aspirin work?

Inhibits thrombin

It reduces platelet aggregation - inhibits COX pathway

Inhinbits coagulation factor production

Inhibits Vit D

Back 17

Ans: It reduces platelet aggregation - inhibits COX

*Aspirin is an antiplatelet, anticoagulants are better for venous thromboembolisms*

Front 18

Which of these drugs does not inhibit platelet function?

Clopidogrel

Dagibiatran

Amximimab

Ticagrelor

Back 18

Ans: Dagibiatran - it is an anticoagulant

*the rest are anti platelets*

Front 19

Case 5:

21 year old medical student on combined pill

Which is true?

She has an increased risk of stroke

She has a reduced risk of PE

She may bleed more easily

She has a family history of a mother and sister of mother with PE - contraindication

Back 19

Ans: She has an increased risk of stroke

*PE risk is increased not reduced*

*Blood is thicker so bleeds less easily*

*family history wouldn't exist because doctor would have never prescribed pill if this was the case*

Front 20

She has an increased risk of stroke and VTE (venous thromboembolism)

Her reactive risk of VTW is 5 X

But her absolute risk is low - how is this?

Back 20

Absolute risk is low compared to older patient because she is young.

So even with the 5X increase she is young so still v low risk of stroke.

Front 21

Which of the following could be present and contribute further to her VTE risk?

Hypercholesteroleamia

Factor V Leiden

Von willerbrands factor deficiency

Diabetes mellitus

Back 21

Ans: Factor V Leiden - increased risk of VTE (doesnt increase risk of stroke though), Factor V Leidein increased VTE 5X In combination with pill which increases overall risk of 30

*diabetes increase for for arterial thrombosis not venous*

Front 22

She has an episode of proximal DVT

Which of the following are not risk factors for arterial thromboembolism?

Smoking

Diabetes

Factor V Leiden


Arterial fibrillation

Back 22

Ans: Factor V Leiden - - factor for venous but not for arterial

Front 23

Chose incorrect answer. Arterial thrombus is?

Platlete rich

May cause pulmonary embolism

Back 23

Ans: May cause pulmonary embolism (that is venous not arterial)

Front 24

Venous thrombosis incorrect answer:

Is fibrin rich

Is participated by circular stasis 


Occurs most commonly in upper limb

May cause pulmonary infaaction

Back 24

Ans: Occurs most commonly in upper limb