WBR0520
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| Author | PageAuthor::Vendhan Ramanujam |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Inpatient Facilities |
| Sub Category | SubCategory::Gastrointestinal, SubCategory::Hematology, SubCategory::Surgery |
| Prompt | [[Prompt::A 55 year old man underwent an abdominoperineal resection for a stage 1 rectal cancer. During the surgery, he received 3 units of packed red blood cells. After successful resection, the patient was sent to the intensive care unit for close monitoring. Five hours later, in the intensive care unit, he started bleeding heavily from his perineal wound. Emergency coagulation studies were ordered and it revealed the following results Prothrombin time: 12 seconds |
| Answer A | AnswerA::Factor VIII deficiency |
| Answer A Explanation | [[AnswerAExp::Incorrect-Factor VIII deficiency (hemophilia A) leads to intraoperative bleeding and it would have lead to bleeding earlier in this long operation. Partial thromboplastin time or activated partial thromboplastin time will be prolonged.]] |
| Answer B | AnswerB::Disseminated intravascular coagulation |
| Answer B Explanation | [[AnswerBExp::Incorrect-Disseminated intravascular coagulation can cause early postoperative bleeding. But prothrombin time, partial thromboplastin time and bleeding time will be prolonged along with a decrease in platelet counts.]] |
| Answer C | AnswerC::Blood transfusion reaction |
| Answer C Explanation | [[AnswerCExp::Incorrect-Blood transfusion reactions can cause diffuse loss of clot integrity and a sudden diffuse bleeding during an operation may be the only evidence of an intraoperative transfusion reaction. In the postoperative period, transfusion reactions usually present as unexplained fever, apprehension, and headache, which all are difficult to interpret in the early postoperative period.]] |
| Answer D | AnswerD::A bleeding blood vessel in the surgical field |
| Answer D Explanation | [[AnswerDExp::Correct-Whenever significant bleeding happens in the early postoperative period with normal coagulation profile, the presumption should always be towards an error in the surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively.]] |
| Answer E | AnswerE::Acquired von Willebrand disease |
| Answer E Explanation | [[AnswerEExp::Incorrect-Acquired postoperative von Willebrand disease is an uncommon disease, which manifests with prolonged postoperative bleeding and laboratory findings like prolonged partial thromboplastin time or activated partial thromboplastin time and prolonged bleeding time.]] |
| Right Answer | RightAnswer::D |
| Explanation | [[Explanation::Whenever significant bleeding happens in the early postoperative period, the presumption should always be towards an error in the surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively. The low platelet count here could be due to post transfusion hemodilution.
Educational Objective:
Whenever significant bleeding happens in the early postoperative period with normal coagulation profile, the presumption should always be towards an error in the surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Factor VIII deficiency, WBRKeyword::hemophilia A, WBRKeyword::von Willebrand disease, WBRKeyword::Disseminated intravascular coagulation |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |