Bleeding & Thrombosis in Practice

Question 1

1) 20 month old boy attends A&E with dad
Refused to walk for 2 days (Walked unsupported for 4 months prior)
Right swollen and warm
Blood aspirated from knee

Most likely diagnosis?

Answer 1

Haemophilia

Question 2

1) How would you determine which kind of haemophilia?

Answer 2

Coagulation factor 8/9 Assay

Question 3

1) Factor VIII = 0% and IX = 73%
Which type of haemophilia is it?

Answer 3

Haemophilia A

Question 4

1) How is haemophilia inherited?

Answer 4

X-linked

Question 5

1) Mum says her dad had haemophilia A, she want’s to know here odds of having another child with it?

Answer 5

1 in 4 (shes a carrier)

Question 6

1) How do you treat the boy?

Answer 6

Recombinant Factor VIII
Atleast 3x per week

Question 7

1) Which infections are a risk of Recombinant Factor VIII?

Answer 7

Hep B & C
HIV

Question 8

1) Other than infections what’s the major complication of Factor 8 concentrates?

Answer 8

Inhibitory antibody development

Question 9

2) 24yr old female student presents with 4 days of easy bruising & small red spots on her ankles
Recently been off colour with flu-like symptoms
Previous tonsillectomy with no bleeding and on OCP.

Which of these symptoms are unlikely?
- Menorrhagia
- Epistaxis
- Buccal Bleeding
- Swollen hot painful leg

Answer 9

Swollen hot painful leg

The rest are possible bleeds from an acquired bleeding disorder

Question 10

2) What is most likely to cause her symtpoms?

Answer 10

Thrombocytopenia

Question 11

2) What could cause her thrombocytopenia?

Answer 11

AML
Aplastic Anaemia
ITP

Question 12

2) She’s bruising spontaneously, what’s her likely platelet count?

Answer 12

10 or less

Question 13

2) What underlying illness could cause ITP?

Answer 13

SLE
EBV
HIV
Lymphoma
(Also use of quinines)

Question 14

3) 70yr old man with excessive bleeds after colectomy for cancer
Bleed from abdo wound but not his drain or line.
He’s had surgery before without abnormal bleeds.
Whats the most likely cause?

Answer 14

LMWH prophylaxis

Not likely to be a bleeding disorder because its a single site

Question 15

3) Why might that patient have been given LMWH prophylaxis?

Answer 15

For VTE because of his:
- Surgery
- Old Age
- Active Cancer

Question 16

4) 65yr old man takes aspirin from h/o TIA.
How does it work?

Answer 16

Reduces platelet aggregation by inhibiting COX-1

Question 17

4) Which of the following drugs are/aren’t anti-platelets?
Clopidogrel
Dabigatran
Abciximab
Ticagrelor

Answer 17

Dabigatran is the only non anti-platelet. (its a DOAC)

C & T target binding of ATP to platelets, preventing activation of platelets

Abciximab inhibits platelet’s receptors for fibrinogen (GP2b/3a)

Question 18

5) 21yr old med student uses cOCP. Which of these is true:
- Increased stroke risk?
- Reduced pulm embolism risk?
- Bleeds more easily from injuries?
- Could have a fh of mother or sisters suffering PE?

Answer 18

Only the increased risk of Stroke

Actually have an increased PE risk

More likely to have a thrombosis than a bleed

Wouldn’t prescribe OCP to someone with a 1st degree relative PE

Question 19

5) Which of these could increase her risk of VTE?
- Hypercholesterolaemia
- Factor V Leiden
- Von Willebrand Factor Deficiency
- DM

Answer 19

Factor V Leiden

Hypercholesterolaemia & DM are arterial risk factors

vWF deficiency –> bleeding not thromboses

Question 20

Which of these are risk factors for arterial thromboembolism?
- Smoking
- DM
- Factor V Leiden
- Atrial Fibrillation

Answer 20

All but Factor V leiden

Question 21

Which of the follow are true of an arterial thrombus?
- Platelet rich
- Mostly on ruptured/ulcerated plagues
- Can –> PE
- Can –> Infarction

Answer 21

Is platelet rich
Is on plagues
Can cause infarction

Won’t cause PE

Question 22

Which of the following are true of DIC?
- Spontaneous disorder of coagulation
- typically –> DVT in lower limbs
- –> Tissue infarction due to microvacular thrombosis

Answer 22

Tissue infarction due to microvascular thrombosis

Can cause DVT but not common

Not Spontaneous

Question 23

Which of these can DIC be a complication of:
- Metastatic cancer
- Normal Pregnancy
- Severe burns
- Septic Shock

Answer 23

Any apart from normal pregnancy

Can occur in non-normal pregnancy