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Medical Emergencies · patient case with 3 questions

Bleeding Risk Assessment

demo: 3 patients presenting for extractions on the same morning

chief: Pre-operative hemostasis assessment

history: Patient A: coronary stent, taking aspirin and clopidogrel. Patient B: hemophilia A. Patient C: family history of easy bruising and prolonged bleeding after minor cuts.

meds: See individual histories

findings: All three require routine simple extractions.

Question 1

Patient A takes aspirin and clopidogrel. What modification is required before a routine simple extraction?

  1. Discontinue clopidogrel only, and continue aspirin
  2. Discontinue both drugs 10 days before surgery
  3. No modification — proceed with local hemostatic measures
  4. Transfuse platelets before the procedure
Show answer and explanation

Correct answer: C. No modification — proceed with local hemostatic measures

  • A. Selective interruption still carries thrombotic risk and is a physician decision, not a routine dental one.
  • B. A 10-day interruption exposes the patient to stent thrombosis, a far graver outcome than local oozing.
  • C. Correct. Dual antiplatelet therapy should not be interrupted for routine dental surgery. The thrombotic risk of stopping outweighs the bleeding risk, which is controlled with pressure, sutures, and local agents.
  • D. Platelet transfusion is reserved for genuine thrombocytopenia, not for pharmacologic inhibition before minor surgery.

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Question 2

Patient B has hemophilia A. Which laboratory test is the relevant screening value?

  1. Platelet count
  2. Partial thromboplastin time (PTT)
  3. Prothrombin time (PT)
  4. Bleeding time
Show answer and explanation

Correct answer: B. Partial thromboplastin time (PTT)

  • A. Platelet count is normal in hemophilia; the defect is in the coagulation cascade, not platelet number.
  • B. Correct. Hemophilia A is factor VIII deficiency, an intrinsic pathway defect, so the PTT is prolonged.
  • C. PT assesses the extrinsic pathway (factor VII) and is used to monitor warfarin; it is normal in hemophilia A.
  • D. Bleeding time reflects platelet function and vessel integrity, both normal in hemophilia A.

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Question 3

Patient C is diagnosed with von Willebrand disease. Which of the following is NOT a feature of this condition?

  1. Isolated prolongation of prothrombin time with normal PTT
  2. Increased capillary fragility
  3. Impaired platelet adhesion and aggregation
  4. Reduced factor VIII levels with prolonged PTT
Show answer and explanation

Correct answer: A. Isolated prolongation of prothrombin time with normal PTT

  • A. Correct — this is the exception. PT is characteristically normal in von Willebrand disease. It is PTT that may be prolonged, because vWF stabilizes factor VIII.
  • B. This is a true feature. vWF contributes to vascular integrity, so capillary fragility increases.
  • C. This is a true feature. Von Willebrand factor mediates platelet adhesion to subendothelial collagen, so its deficiency impairs adhesion and aggregation.
  • D. This is a true feature. Loss of vWF destabilizes factor VIII, lowering its level and prolonging PTT.

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