Point-of-care coagulation testing — MCQs

A 35-year-old patient is brought into the emergency department post motor vehicle crash. Stabilization of the patient in the trauma bay requires endotracheal intubation. The patient has a laceration on the femoral artery from shrapnel and seems to have lost large quantities of blood. The patient is transfused with 13 units of packed red blood cells. His vitals are T 96.5, HR 150, BP 90/40. Even with the direct pressure on the femoral artery, the patient continues to bleed. Results of labs drawn within the last hour are pending. Which of the following is most likely to stop the bleeding in this patient?

An otherwise healthy 23-year-old man comes to the physician because of a 3-day history of mild persistent bleeding from the site of a tooth extraction. He has no prior history of medical procedures or surgeries and no history of easy bruising. He appears well. Vital signs are within normal limits. Laboratory studies show: Hemoglobin 12.4 g/dL Platelets 200,000/mm3 Serum Prothrombin time 25 seconds Partial thromboplastin time (activated) 35 seconds Deficiency of which of the following coagulation factors is the most likely cause of this patient’s condition?

A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

A 59-year-old woman comes to the physician because of left leg swelling that started after a transcontinental flight. A duplex ultrasound of the left leg shows a noncompressible popliteal vein. A drug is prescribed that inhibits the coagulation cascade. Two weeks later, laboratory studies show: Platelet count 210,000/mm3 Partial thromboplastin time 28 seconds (normal: 25-35) Prothrombin time 12 seconds (normal: 11-13) Thrombin time 15 seconds (control: 15 seconds) Which of the following drugs was most likely prescribed?

A 71-year-old woman is brought to the emergency department following a syncopal episode. Earlier in the day, the patient had multiple bowel movements that filled the toilet bowl with copious amounts of bright red blood. Minutes later, she felt dizzy and lightheaded and collapsed into her daughter's arms. The patient has a medical history of diabetes mellitus and hypertension. Her temperature is 99.0°F (37.2°C), blood pressure is 155/94 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. The patient's exam is notable for fecal occult blood positivity on rectal exam; however, the patient is no longer having bloody bowel movements. The patient's lungs are clear to auscultation and her abdomen is soft and nontender. Labs are ordered as seen below. Hemoglobin: 7.1 g/dL Hematocrit: 25% Leukocyte count: 5,300/mm^3 with normal differential Platelet count: 182,500/mm^3 Two large bore IV's are placed and the patient is given normal saline. What is the best next step in management?

A 65-year-old man presents to the emergency department by ambulance following a motor vehicle accident. He was a restrained passenger. At the hospital, he is bleeding heavily from a large wound in his left leg. A review of medical records reveals a history of atrial fibrillation for which he takes warfarin. His international normalized ratio (INR) 2 days ago was 2.6. On physical exam he is cool and clammy. The vital signs include: heart rate 130/min and blood pressure 96/54 mm Hg. Aggressive resuscitation with intravenous normal saline is begun. Which of the following is the next best step to correct this patient's underlying coagulopathy?

A 58-year-old cirrhotic man with ascites undergoes large volume paracentesis (6 liters removed). Four hours later, he becomes hypotensive (BP 80/50 mmHg) and tachycardic (HR 115/min). Labs show: Cr 2.1 mg/dL (baseline 1.0), Na+ 128 mEq/L, Hct 38%. What is the most appropriate immediate management?

A 42-year-old woman with prolonged vomiting from gastroparesis is admitted with weakness. Labs show: K+ 2.1 mEq/L, pH 7.51, HCO3- 42 mEq/L, Mg2+ 1.4 mg/dL. She receives 80 mEq of IV potassium chloride over 24 hours, but repeat K+ is 2.3 mEq/L. What explains the refractory hypokalemia?

A 65-year-old diabetic man with TURP syndrome presents with confusion, nausea, and seizures 2 hours post-operatively. Labs show: Na+ 115 mEq/L, serum osmolality 240 mOsm/kg. He weighs 70 kg. What is the target sodium correction rate and fluid management strategy?

A 50-year-old man is 5 days post-operative from a Whipple procedure. He has had high nasogastric output (1500 mL/day) and has been NPO. Labs show: Na+ 132 mEq/L, K+ 2.9 mEq/L, Cl- 88 mEq/L, HCO3- 38 mEq/L, pH 7.52. Urine chloride is 8 mEq/L. What is the appropriate management?