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Case Study: Bleeding Time

Here is a note from a new acquaintance, colleague Marjorie (Marj) Montanus: Hello, George. I am the new Hematology/Coag instructor in the Idaho State University Medical Laboratory Science program replacing Sonya Nehr-Kenat. We have been using an old case study that describes a “friable, soft clot after 24 hours of incubation at 37°C.” Could you explain more about what that term means and what diagnostic info it gives to this case study? Here is the case:

A 39 year old woman was readmitted with vaginal bleeding several weeks following an abdominal hysterectomy. The patient and family bleeding histories were negative, but the patient had been taking aspirin and an antihistamine regularly for many months before the operation. Her Ivy bleeding time was greater than 10 minutes, and her specimen had a friable, soft clot after 24 hours’ incubation at 37°C, her remaining coagulation tests were normal.

  • What is the most probable diagnosis?
  • What additional tests should be performed to confirm the diagnosis?
  • What type of therapy should be initiated?

Participants, please provide your answers in the comment section.

George provided this answer: Hello, Marj, friable means soft, easily “crumbled,” fragile. I suspect the writer is looking for thrombocytopenia or a functional platelet disorder, which could result in a soft, friable clot after incubation, although hypofibrinogenemia or dysfibrinogenemia could also account for these findings. You may want to update this case, as the bleeding time test and clot retraction test are obsolete. One reliable method for detecting a platelet functional disorder is aggregometry. For a fibrinogen deficiency or disorder, you would need to perform a fibrinogen assay. Alternatively, the TEG and ROTEM are excellent at detecting either disorder. If this is a platelet disorder, she would need to D/C the aspirin. If bleeding is severe and the platelet count is low, about all we have is platelet concentrate to treat, which is only helpful in acute situations. For a fibrinogen problem there is CRYO or a fibrinogen concentrate. Best wishes in your new position at Idaho State, and feel free to send me questions at any time.

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