Chapter 1: What is the introduction to the case of coagulopathy?
Welcome back, Clinical Problem Solvers. Maddie and Yousef here. At CP Solvers, our mission is to make clinical reasoning accessible to learners worldwide. We invite you to join us for our live virtual morning reports, where we break down cases and sharpen our diagnostic reasoning together. Now over to you, Yousef.
Thanks, Maddy. Just a quick reminder, this podcast is for educational purposes only and is not a substitute for medical advice. Patient details have been modified to protect their privacy and the views expressed are our own, not those of our employers. Now, let's dive into the case.
Enjoy the show.
Hello, everyone. I'm super excited to be back with the schema team for another podcast recording. We were just hanging out and talking about life updates before starting. And that's why I sound so happy because, you know, being with these three people really fill my cup. Maddie, how are you doing?
That was the best intro ever. Love the enthusiasm. Totally agree. Hanging out with you guys fills my cup. I'm doing well. I feel like the only updates I give are baby updates. So I guess there's more to my life, but not really. So things are good. Like back into residency, hanging out with little Aaron. Life is great and excited for this case. What about you, Yusuf?
Any updates to share with the crowd?
All good, all good. I was just reading about the new Hantavirus that may have transmitted from human to human. And now that we've lived through the pandemic, I'm like, oh no, I've seen this movie before. Not again. Oh gosh, oh gosh. Yeah, on like a cruise ship in the Canary Islands and I'm like reading all about it. I was like, oh my God, hopefully it doesn't spread.
Mark, any insider infectious disease news?
Well, building off that, I also saw someone talking about using ivermectin for hantavars on Twitter. I was like, oh, no, not again. Already? I thought this was done. But no, and Maddie, I think this is just going to turn into a baby podcast.
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Chapter 2: What are the initial symptoms and history of the patient?
So, yeah, audience, just look out for that transition to the baby podcast.
Maybe we can be sponsored by some diapers or some bottles. Yeah.
I think it's so funny how there's designer diapers, designer bottles. It's crazy. The whole baby industry is pretty insane, honestly. It is so much. It is so much.
Anyways, Yusuf, you have a case for us. So excited.
I've been thinking about this case for a while, and I'm really excited to present it to you all. So I'm going to go ahead and get started. This is a 75-year-old man who has a history of dementia from prior CVA. And he had a ground-level fall where he fell down the stairs. So he was admitted to the hospital, found to have a right thigh hematoma for which IR was consulted.
And IR did an embolization of that hematoma. During that admission, he had decrease in hemoglobin that was like further drop in his hemoglobin. So he had to undergo another procedure, which was also an embolization. And that bleed was next to the vastus lateralis muscle. And he did well afterwards, was discharged. And then two weeks after, he started having tingling in his left forearm. So he had
pain in his left hand, along with paresthesias of the left hand. And he felt like weak in that specific hand. So I gave a lot of information. I'm going to throw the mic to Noah. Just like, how do you think about this case? And just get your thoughts.
Yeah, interesting, interesting start. And just so I know, was the I saw hematoma on the left side, the same side as the arm.
So the initial hematoma was actually in the groin. So it was in the hip area. They did a femoral artery access and did embolization that way. And that was on the right. And this time he's coming with left hand symptoms.
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Chapter 3: How did the patient's condition progress after the initial treatment?
And first of all, I didn't know you could consult hematology from the OR. That was news to me. But I think, you know, right now we really I'm concerned about bleeding in this person, obviously. And so let's maybe try to break down why people bleed and then we can try to localize why he's why he's bleeding. So I, you know, in clinical reasoning, we love kind of an anatomical approach.
And I think that works well also for bleeding. And so I think of if you're bleeding, there would be a lesion either in the blood and And you can think of the components of the blood, including platelets and coagulation factors. So is it a lesion in the blood? Is it a lesion in the vessel wall? And that can be either an inflammatory process like a vasculitis or a non-inflammatory vasculopathy.
Or is it an issue with von Willebrand factor, which you can think of as kind of what connects the two between the vessel wall and the components of the blood? So again, think of is it an issue with the blood and is it an issue with coagulation factors, platelets, vessel wall, or von Willebrand factors? I think for this person, what we've heard is the PTT is prolonged.
It's helpful to just look this up, but if you type in the coagulation cascade, if you recall, there's the intrinsic pathway and the extrinsic pathway. The PT is a part of the extrinsic pathway and the PTT is a part of the intrinsic pathway. And so this person with the prolonged PTT, I'm worried, has a lesion in the intrinsic pathway.
And maybe I'll pass the mic to Noah if you want to talk more about like in him with this elevated PTT, where you think the lesion could be within that.
That was a beautiful explanation, Maddy. Before going into a little bit about the bleeding disorder, to recap, so we have a patient that had trauma, had a fall, and then had multiple hematomas. And now he's presenting with this compartment syndrome. And the compartment syndrome, you can think of the presentation much like acute limb ischemia. It's pulseless. It's painful.
But the main difference, it's going to be tense and it's going to be swollen. And the compartment syndrome, it's basically because you have like this inelastic fascia and then something is increasing the pressures inside the fascia. And in our case, we opened it up and we saw it was blood. It could be pus, right? It could be a bone that's broken and that's bleeding.
It could be a clot that's preventing the blood flow to get back. But in our case, the patient is bleeding inside his fascia. So with the PTT being elevated, that puts us into the pathway that Maddy described. And the next step in the investigation would be to do a mixing study. And the reason why we would do a mixing study is because if we get...
blood that we know is not diseased and we mix with the patient's blood, if the patient's blood has a deficiency in one of the coagulation factors, that deficiency will be corrected by the fresh non-diseased blood. However, if we let the blood incubate for a while and the deficiency initially corrects, but then it starts becoming apparent again, we can determine that actually what is happening is
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Chapter 4: What diagnostic tests are essential for evaluating bleeding disorders?
You would use CT?
Yeah, I'd probably get a pan scan. I mean, you know, obviously, if the patient can, you know, give us some focality in their symptoms, you know, if they've been having some chronic cough or some chronic GI symptoms or anything like that, that'd be helpful to, you know, focus in on our evaluation. I'd definitely be asking them about, you know, prior symptoms.
um cancer screening did they get their colonoscopies are they someone that you know was a population that would benefit from prostate cancer screening but honestly like especially with this severe presentation and just like the patient's older age and i would also be investigating the stroke a little more too um because you know you just didn't tell us that this patient had hypertension hyperlipidemia diabetes smoking you just told us about a history of stroke
So I'd be curious when that happened. And was that a hint that this patient had a hypercoagulable state in the past, which, you know, as we know, in older patients, cancer is the most common cause.
It really, it probably wouldn't like influence the workup, but it would just be interesting if that was the kind of first manifestation of like a malignancy was a stroke, and now we have a factor inhibitor. But I think at the end of the day, like you, you probably need, you know, a pan scan just to see if you can, you know, identify anything. And then, you know, things like
you know, myeloma as well. So I would probably do a paraprotein workup as well. Cause you said, did tell us that that MCV was like, I want to say like 97 or 96. We love, we love macrocytosis and MCV here on clinical problem solvers. And you know, a lot of paraprotein disorders like myeloma and And other ones can cause a, you know, a macrocytic anemia.
And maybe that was just, it's possible that was just from, you know, a reticulocytosis from a patient that was, you know, bleeding, possibly. Or they have, you know, B12 deficiency or something else like that for an unrelated reason. But yeah, I'd probably do PANSKIN and a, you know, periprotein workup to start. And, you know, LBH as well could be helpful.
Okay.
And then we'll ask Noah for any other thoughts on maybe the hardest question about treatment because I know Yusuf is putting in the chat. Yeah, any other thoughts, Noah, on tackling treatment maybe?
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