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Case Study

How to Prepare a Case Study

Your case study should be in the following format if possible:

Patient's initial: JM

Diagnosis: mild hemophilia A

Age: 67

Past Medical History: Pt. has had a life-long history of bleeding. He has no history of auto-immune disorders. He is hypertensive and taking medications to control.

Surgical History: At the age of 18, he had a tonsillectomy and 8 days post procedure, he developed bleeding which required cauterization. At 37 years of age, he had sinus surgery and 8 days later developed epistaxis which required packing without further intervention. He also had dental extractions with oozing for 72 hours. Pt underwent L total hip arthroplasty 8/30/98 after being diagnosed with mild hemophilia A (~30%)

Social History: Individual is married and has four grown children. He is currently working as director of operations at a local business. He has no family history of a bleeding disorder.

Chief Complaint or history of the event: Pt. was seen by the coagulation clinic for a persistent serous drainage from wound near the L THA surgical site. The wound was cultured and found to be positive for peptostreptococcus magnus.

Physical Exam: Pleasant man in no acute distress. Mildly obese, his skin has some actinic changes to his ear and his back, He does have an area of bright red granulation at the superior aspect of his left hip incision which is draining some serosanguinous fluid without foul odor. Other body systems were normal on exam. BP 138/84, Pulse 80.

Lab data: Factor VIII 45%, factor IX 119%; factor XIII screen was unremarkable. Prothrombin time (PT) and activated partial thromboplastin time (APTT) were within normal limits. Thrombin time (TT) was also normal. Sed rate 27 (0-22 mm/hr), C-reactive protein elevated at 1.46 (0.020-0.800).

Radiologic Studies (if possible): Left THA. Lucent areas adjacent to the femoral component, likely due to granulomatous reaction. Lucent zone adjacent to
the acetabular component.

Impression: Infected L THA

Treatment: The infected components were removed under coverage of DDAVP and continuous infusion of factor and pt was placed on the appropriate antibiotic therapy. Surgery for replacement of the hip was performed 8 weeks later with DDAVP and factor coverage. Pt was dismissed post op with follow up factor VIII infusions and monitoring maintaining factor VIII levels above 50%.

Outcome: Pt traveled to his home and two months later was admitted to his local hospital with acute onset of bleeding, APTT 3 times normal and a factor VIII level of <1%. He was found to have a potent inhibitor of 106 Bethesda Units. No products were available for infusion and patient traveled to our facility again for evaluation. Pt was given an APCC to control and stabilize bleeding he was experiencing. Pt was informed and consented to be involved in a trial of Rituximab in an attempt to eliminate the inhibitor. Pt went through 4 weekly doses of Rituximab and was allowed to travel to home with APCC infusions for bleeding episodes. Pt had blood tests monitored per a protocol and his inhibitor subsequently decreased to <5 B.U. He has a follow-up visit scheduled for October 2002 for another inhibitor and VIII level.