Question

• 15-year-old male, Mohammed, from Saudi Arabia -Admitted to the ER after automobile accident . Several superficial cuts and bruises on head and arms • Bleeding profusely, more bleeding than expected from the nature of his wounds . Consider possible causes of this abnormal bleeding and the lab tests that might be used to differentiate and diagnose the cause. • Petechiae were noted on Mohammed's extremities. Blood work was ordered Laboratory Studies Hematology WBC 10.5 x 10 RBC 23 X 10L HD 66L Het 0.191 LL Plecu 133 x L Hemostasis PT 11.sec APTT 25.6 sec • Question 1: -Explain how these laboratory tests confirm that the patient's bleeding is related to a defect in primary hemostasis rather that secondary hemostasis. • Question 2: - Is the bleeding more likely related to problems with the vascular system or with platelets? Why? • Question 3: - Is this profuse bleeding with the presence of petechiae consistent with the platelet count? Why? • Question 4: - What additional testing would be helpful to identify the cause of the patient's excess bleeding? - Mohammed's hematology report - At least 65% of platelets were large and giant forms with intense granulation. Question 5: - Is there a possibility that the patient's platelet count is spuriously increased or decreased? Why?

Answer 1

Question no 1)

Primary hemostasis is a procoagulation clot forming process associated with the initiation and formation of the platelet plug. Secondary hemostasis also a procoagulation clot forming process and it is associated with the propagation of the clotting process via the intrinsic and extrinsic coagulation cascades.

• A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia.Here Mr.mohammed is having platelet count value less than normal range that is below 150,000 which indicates problem with primary hemostasis.

Question no 2)

In Mr .mohhameds condition bleeding occurs due to reduction in the value of platelet that supports the process of primary hemostasis. As far as concerned there is no evidence of vascular disorder in his laboratory values .It can be seen that his platelet count is below normal range indicating that bleeding is due to platelet cells .

Question no 3)

Yes ,while looking into the laboratory values it can be found that Mr.mohhamed is having thrombocytopenia a condition where there is reduction in platelet cells. Petechiae is a clinical symptom of thrombocytopenia .This profuse bleeding and petechiae occured due to platelet cell count less than 150,000 that is thrombocytopenia

Question no 4)

Additional tests to find cause

• Bone marrow aspiration test
• Bone marrow biopsy
• Liver function tests
• Reticulated platelet test
• Test for medication allergy
• Test for abnormal antibodies
• Blood cultures
• CT of spleen
• Ultrasonography of spleen

Question no 5)

No , in this condition petechiae over the extremities shows that the decrease in platelets has not occured all of a sudden . It's having a specific cause for the occurance of thrombocytopenia which can be ruled out by doing further laboratory tests.