Definitions
What coagulation factor is not synthesized in the liver?
where is it found if not in the liver?
Factor VIII Plasminogen
A 21-year-old man comes to the emergency room because of a 2-hour history of swelling and severe pain in his left lower leg. He has no history of serious illness or trauma. His father had a pulmonary embolism at the age of 30 years. The patient has smoked one pack of cigarettes daily for the past 3 years. He appears distressed. He is 173 cm (5 ft 8 in) tall and weighs 92 kg (203 lb); BMI is 31 kg/m2. His temperature is 37.0°C (98.6°F), pulse is 94/min, respirations are 17/min, and blood pressure is 130/78 mm Hg. Physical examination shows a tender and mildly swollen left lower leg; dorsiflexion of the left foot causes severe pain in the calf. Laboratory studies show a platelet count of 184,000/mm3, prothrombin time of 11 seconds, partial thromboplastin time of 26 seconds, and positive fibrin split products. Ultrasonography of the left leg shows incompressibility of the popliteal vein with a hyperechoic mass and absent blood flow. The patient is administered a 5000 IU intravenous bolus of unfractionated heparin followed by a constant infusion. Six hours later, the partial thromboplastin time is 28 seconds. Which of the following is the most likely underlying cause of this patient's symptoms?
Hyperhomocysteinemia
Antithrombin III deficiency
Factor V Leiden
Protein C deficiency
Antiphospholipid syndrome
Antithrombin III deficiency
Antithrombin III deficiency (AT III deficiency) is an inherited autosomal dominant hypercoagulable disease. AT III inhibits coagulation by binding to and inactivating the coagulation factors II (thrombin) and X. Heparin works by potentiating the binding of AT III to thrombin and factor X. This patient's PTT remains normal despite heparin administration because heparin requires AT III to achieve its effect. Patients with AT III deficiency can tolerate higher doses of heparin (also known as heparin resistance) without showing any changes in PTT. If therapeutic goals are not achieved with heparin (1.5 to 2.5 times the upper limit of the normal range of PTT), additional antithrombin concentrate may be needed.
FUN SLIDE
softball!!!
what are the Vitamin K dependent clotting factors
II, VI,IX, X
A 46-year-old man is admitted to the hospital with a 3-day history of productive cough with purulent sputum and fever with chills. On the second day of admission, he develops bloody vomiting, altered mental status, and multiple red spots all over the body. He is oriented only to self. His temperature is 39.3°C (102.7°F), pulse is 110/min, respirations are 26/min, and blood pressure is 86/50 mm Hg. Physical examination shows ecchymoses on both lower extremities. Crackles are heard at the right lung base. Laboratory studies show a platelet count of 45,000/mm3, with a prothrombin time of 44 sec and partial thromboplastin time of 62 sec. D-dimer concentrations are elevated. What acquired bleeding disorder is most likely cause of this patient's ecchymoses?
DIC
Disseminated intravascular coagulation (DIC) can occur due to sepsis, a condition that is characterized by poor general condition, fever, tachycardia, tachypnea, and hypotension following a primary infection. Given this patient's fever, productive cough, and lung crackles, his sepsis is likely due to severe community-acquired pneumonia. His low blood pressure and altered mental status should raise concern for progression to septic shock.
What acquired bleeding disorder can be treated with Desmopressin?
Renal Disease (Dialysis or transplant is generally considered definitive treatment)
A 27-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of a 2-day history of vaginal bleeding and epistaxis. She missed her last prenatal visit 2 weeks ago. Physical examination shows blood on the posterior pharyngeal wall. The uterus is consistent in size with a 23-week gestation. Her hemoglobin concentration is 7.2 g/dL. Ultrasonography shows an intrauterine pregnancy with a small retroplacental hematoma and absent fetal cardiac activity. Further evaluation of this patient is most likely to show which of the following findings?
Decreased prothrombin time
Increased factor V concentration
Decreased partial thromboplastin time
Decreased fibrinogen concentration
Decreased fibrinogen concentration
DIC is characterized by systemic consumption of both procoagulant and anticoagulant clotting factors, usually resulting in abnormal bleeding. Placental abruption and retained fetal products are both risk factors for the development of DIC in pregnant women because of the systemic release of thromboplastin and resulting dysregulation in the coagulation cascade. Other obstetric complications that increase the risk of DIC include amniotic fluid embolism and preeclampsia. Additional laboratory findings that may be seen in DIC include thrombocytopenia, increased PT and PTT, increased bleeding time, increased D-dimer, and decreased factor V concentrations.
what acquired bleeding disorder causes hemorrhagic disease of newborn?
Vitamin K deficiency
A 33-year-old woman is brought to the emergency department after she was involved in a high-speed motor vehicle collision. She reports severe pelvic pain. Her pulse is 124/min and blood pressure is 80/56 mm Hg. Physical examination shows instability of the pelvic ring. As part of the initial emergency treatment, she receives packed red blood cell transfusions. Suddenly, the patient starts bleeding from peripheral venous catheter insertion sites. Laboratory studies show decreased platelets, prolonged prothrombin time and partial thromboplastin time, and elevated D-dimer. A peripheral blood smear of this patient is most likely to show which of the following findings?
Schistocytes (helmet like) characteristic of DIC
if a patient has amyloid proteins in their plasma and a mixing study is done with control plasma, what would the aPTT show
signifigantly increased time as normal factor X would be inhibited by amyloid proteins.
Four days after admission to the hospital for acute pancreatitis, a 41-year-old man develops hypotension and fever. His temperature is 39.1°C (102.3°F), pulse is 115/min, and blood pressure is 80/60 mm Hg. Physical examination shows warm extremities, asymmetric calf size, and blood oozing around his IV sites. There are numerous small, red, nonblanching macules and patches covering the extremities, as well as several large ecchymoses. His hemoglobin concentration is 9.0 g/dL. A peripheral blood smear shows schistocytes and decreased platelets. Which of the following sets of serum findings are most likely in this patient?
C (DIC)
These serum findings are most consistent with DIC as evidenced by increased prothrombin time (PT), partial thromboplastin time (PTT), and D-dimer. DIC is a disorder characterized by systemic activation of the clotting cascade with microthrombi formation, which results in the exhaustion of all clotting factors. Microthrombi precipitate microangiopathic hemolytic anemia, which results in schistocytes on peripheral blood smear. The depletion of clotting factors prolongs the PT and PTT. Fibrinogen is activated in the clotting cascade to become fibrin; thus, a decrease in fibrinogen is expected in patients with DIC.