Internal-Medicine

Questions: 59–73 111
Questions 70 through 73
(A)
(B)
(C)
(D)
von Willebrand’s disease
hemophilia A
hemophilia B
thrombotic thrombocytopenic purpura
(TTP)
For each patient with a bleeding disorder, select
the most likely diagnosis.
70. A 23-year-old man presents with prolonged
nose bleeds. He has always noted easy bruising,
and ongoing bleeding after minor cuts.
There is no prior history of surgery or dental
procedures. His hemoglobin is 14.5 g/dL,
platelets 200,000/mL, and PT/PPT is normal.
Further testing reveals that the bleeding time is
elevated; the factor VIII level is reduced, as is
the ristocetin cofactor assay. (SELECT ONE)
71. An 18-year-old man develops excessive bleeding
2 hours after wisdom tooth extraction. He
has a history of easy bruising after playing
sports, and of minor cuts that rebleed. His
examination is normal, except for the tooth
extraction site, which is still oozing blood. His
hemoglobin is 14.8 g/dL, platelets 230,000 mL,
PT is normal, and partial thromboplastin time
(PTT) is elevated. A bleeding time is normal,
factor VIII level is reduced, factor IX is normal,
and ristocetin cofactor assay is normal.
(SELECT ONE)
72. A 19-year-old man is brought to the hospital
after injuring his knee playing football. The knee
is swollen and painful to move. He has no prior
history of bleeding disorders. Arthrocentesis
of the knee reveals 20 cc of blood. Further
investigations show that his platelets are
170,000/mL, PT is normal, PTT is elevated,
bleeding time is normal, factor VIII is normal,
factor IX is reduced, and the ristocetin cofactor
assay is normal. (SELECT ONE)
73. A 27-year-old woman presents with nose
bleeds, rash on her feet, and fevers. She looks
unwell, pale, jaundiced, and there are multiple
petechiae on her feet. The lungs are clear, heart
sounds normal, and abdomen is soft with no
palpable spleen or liver. Her bilirubin is 2 mg/dL
(mostly indirect), aspartate amino transferase
(AST), alanine amino transferase (ALT), alkaline
phosphatase (ALP) are normal. The hemoglobin
is 8.7 g/dL, platelets 24,000/mL, PT/PTT
normal, and bleeding time is elevated. The
blood film reveals anemia, thrombocytopenia,
and red cell fragments. (SELECT ONE)