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Prolong PT/PTT Case Report. Ri 鄭千威. Patient Infomation. Name: 謝 XX Gender: female Age: 19 Chart Number: 5075664. Past history. 1.DM(-), HTN (-), Hyperlipidemia (-) 2.Other major systemic disease: gouty arthritis 3.Alcohol consumption: denied 4.Smoking: denied 5.Allergy: denied

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Prolong PT/PTT Case Report

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Prolong pt ptt case report

Prolong PT/PTT Case Report

Ri 鄭千威

Patient infomation

Patient Infomation

  • Name:謝XX

  • Gender: female

  • Age: 19

  • Chart Number: 5075664

Past history

Past history

  • 1.DM(-), HTN (-), Hyperlipidemia (-)

  • 2.Other major systemic disease: gouty arthritis

  • 3.Alcohol consumption: denied

  • 4.Smoking: denied

  • 5.Allergy: denied

  • 6.Surgical history: denied

  • 7.Family hx not contributory

Brief history

Brief History

  • Jan – Feb 2006, felt short of breath, weakness while climbing to her classroom on 4th floor

  • URI symptoms and exertional dyspnea developed in March then went to 耕莘 hospital on April 18.

  • Cardiac ECHO showed dialated LA and LV with LEVF = 20%, severe MR and moderate TR and PR without vegetation

Prolong pt ptt case report

  • Hospitalized from July 27 – Aug 5 due to SOB and cough with sputum for 1 wk

  • Heart ECHO on July 28:

    pericardial effusion without tamponade sign, LVEF~16%, mod-severe MR, mod TR, PR with pul. HTN, without evidence of IE

  • Abd ECHO on July 29:

    All normal except a 2.61 cm left renal cyst

  • Refer to NTU OPD on Aug 10

Prolong pt ptt case report

  • NTU OPD on Aug 24: decided for heart transplant

  • Hospitalized at 耕莘 H. Sep 25 – Sep 30 due to SOB, vomiting

  • Hospitalized at 耕莘 H. Oct 2 – Oct 5

    due to SOB

Prolong pt ptt case report

  • Oct 5: Request transfer to NTUH ER with development of SOB, vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation

  • Tremor cause unknown may be due to primperan related EPS

Lab findings at er 10 05

PH 7.47

PCO2 36.0

PO2 114.4

HCO3 25.6

WBC 4.92

RBC 2.94

HB 9.2

PLT 206.0

UN 38.5

CRE 1.8

Lab findings at ER (10/05)

Physical finding

Physical finding

  • Conscious clear until E1VTM4 (10/14)

  • Conj: anemic (-) Sclera: icteric (-)

  • Pupils: isocoric (+) Light reflex : R/L ( + / + )

  • Throat: injected (-) Gum bleeding (-)

  • Neck: supple (+) , LAP (-), JVE (-), goiter (-)

  • Chest: symmetric expansion

  • BS: clear (+), rales (-), wheezing (-), crackle (-)

  • Heart:

  • PMI : at 6 ICS 3 fb, to LMCL

  • heart sound: regular heart beat

  • murmur: systolic murmur at mitral area, diastolic murmur over pulmonary valve area

  • Abdomen: inspection: soft (+), flat (+),

  • tenderness (-), rebounding tender(-), shifting

  • dullness (-) , central obesity (-), striae (-)

  • Liver: impalpable

  • Spleen :impalpable

  • Bowel sound : normoactive

  • Back: CV angle knocking pain (-)

  • Ext.: non-pitting edema,

  • tremor of extremities (+), purpura over forearms & cannulation wounds ;(+),Cyanosis of finger tips & toes(+)

Treatment course

Treatment course

  • Oct 6: Unasyn: new onset fever (38.5) , resp s/s (cough + sputum)

    • Blood: no pathogen

    • Sputum: Gram (-) rods1+, Gram (+) cocci in chains3+

      WBC 4920

      CRP 0.13

      U/A: negative findings

      BNP 3621.47

  • Oct 9: cough with occasional blood tinged sputum

  • Oct 10: BT↑:39℃ Tazocin: nosocomial infection, new fever onset, persistent cough with sputum

    WBC 7250

    CRP 1.46

    U/A: negative findings

    • Blood: no pathogen

    • Sputum: few Enterobacter cloacae

Prolong pt ptt case report

  • Oct 11: fever flare up 39.4 ℃, tremor

    On CVP, O2 mask

    Hb↓, blood tinged sputum, susp. pulmonary hemorrhage


  • Oct 11 (1700): transfer to 3B1 for ionotropic support

    Dx: CHF NYFc IV, Cardiac ECHO: LVEF=20%, 4 chamber dilatation

Prolong pt ptt case report

  • Oct 11 (2000): sudden attack of partial seizure with 2nd generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


  • Oct 11 (2100): profound shock after seizure despite full dose ionotropic

    On ECMO (L’t femoral a & v), on R’t femoral CVP

Lab findings


Oct 11:

Anti-Nuclear Antibody : -

C3 Quantitation: within normal limit

C4 Quantitation : within normal limit

RA Factor : -

Anti-ds DNA : -

Oct 12

Adenovirus ab: -

Coxsackievirus ab B1-B6: -

CMV IgM ab: -

Anti-CCP: -



Anticardiolipin: -


Rheumatoid arthritis


Rheumatoid arthritis

Wegener's granulomatosis

Wegener’s granulomatosis

Anti-phospolipid dz

Lab findings

Lab findings1


Oct 13

HBsAg: Non reactive

Anti-HBs: reactive

HBeAg: Non reactive

Anti-HBe:Non reactive

Anti-HBc: reactive

Anti-HCV: Non reactive

Anti-HAV: reactive

STS: non reactive

Anti-HIV: negative

Lab findings

Prolong pt ptt case report

  • Oct 12: CAVH due to anuria, hyperkalemia

  • Oct 13: IABP, R’t femoral a.

    • Transfer to 4FI

      • Dopamine 20 ml/hr taper to 10 before transplant

      • Levophed 8 ml/hr DC 10/19

      • Isuprol 2 ml/hr DC 10/18

  • Oct 14: E1VTM4: fever switch to fortum + vancomycin

    • Blood: no pathogen

    • Sputum: Enterobacter cloacae3+

    • Prophylaxis MRSA infection

      CRP: 8.18

      WBC: 11020

  • Oct 16: bronchoscope

    • diffuse bloddy secretion, pulmonary parechyma hemorrhage is likely

    • no obvious airway injury

  • Oct 17: LA drain with artificial ASD: toes and finger tip darken

    • Anterior tibial a, dosalis pedis a. L +/+ R +/+

  • Oct 18: aortic ligation and aortic valve suturing

    • PGE1 and nitroderm for improving distal circulation

  • Oct 21: heart transplant

  • Prolong pt ptt case report





    Prolong pt ptt case report



    Prolong pt ptt case report



    10/11 PT 20.3 -> 23.7

    PTT 30.3 ->35.7

    10/14 PT 45.3

    PTT >200

    Prolong pt ptt case report

    Oct 10

    Prolong pt ptt case report

    Oct 12

    Prolong pt ptt case report

    Oct 20, after LA drain

    Prolong pt ptt case report


    B type natriuretic peptide

    a protein produced bythe ventricles of the heart

    test has a negative predictive value of at least 96%, so heart failure can confidently be ruled out for patients in the normal range

    B-type natriureticpeptide


    Dilated cardiomyopathy

    Dilated cardiomyopathy

    Def: dilation & impaired contraction of one or both ventricle

    Def: LVEF <40%

    • Imparied systolic function -> HF

      common s/s: progressive dyspnea with exertion, impaired exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema






    Infective (coxsaki, CMV, HIV, adeno)


    Familial storage disease (glycogen storage dz)

    Deficiency (e-, nutrient)

    Connective tissue disorder (SLE, RA)

    Infiltration & granulomas (maglinancy, amyloidosis)

    Neuromuscular (Muscular dystrophy)

    Toxic reaction (alcohol, drugs-doxorubicin, cyclophosphamide)

    Peripartum heart disease


    Harrison's Principles ofInternal Medicine, 15th Edition



    • Most downhill course

    • Death due to CHF, arrythmia, sudden death

    • Systemic embolization

    • Rx for heart failure

      • Salt restriction

      • Beta blocker carvedilol 3.125 mg qd -> 20-50 mg q12h

      • ACEI captpril 6.25 mg po tid

      • Digitalis 0.5 mg po/iv ->0.25 mg q6h

      • Diuretics spirolactone 25 mg po qd

      • Avoid alcohol, NSAID

      • transplant



    Def: expectoration of blood from the respiratory tract

    • From sputum blood streak to large amount of pure blood

    • Dx: respiratory track vs GI source

    • GI tract -> a dark red appearance and an acidic pH,

    • Respiratory track-> bright red appearance and alkaline pH


    Systemic coagulopathy, anticoagulant, thrombolytic agents

    Primary vascular source



    ↑pul venous pressure (MS)

    Tracheobronchial source





    Airway trauma

    Froeign body

    Pulmonary parenchyma source

    Lung abscess



    Fungus ball

    Lung contusion

    Idiopathic pulmonary hemosiderosis

    Goodpasture syndrome

    Wegener’s granulomatosis

    Lupus pneumonitis


    Harrison's Principles ofInternal Medicine, 15th Edition



    • blood-streaking of sputum or small amounts of pure blood -> priority -> diagnosis, (gas exhange usually unaffected)

    • massive hemoptysis

      • maintaining adequate gas exchange

      • preventing blood from spilling into unaffected areas of lung,

      • avoid asphyxiation.

    • rest and partially suppressing cough may help the bleeding to subside

    • If too severe may need endotracheal intubation and mechanical ventilation

    • laser phototherapy, electrocautery, embolotherapy, and surgical resection of the involved area of lung.

    C reactive protein

    C reactive protein

    • Why high fever, but low CRP?

    • CRP produced by hepatocytes stored in ER

    • During acute phase response, CRP catabolic rate independent of plasma level CRP therefore ambient level depend on syn rate

    Prolong pt ptt case report

    • elevated CRP value is not specific for any condition,

    • a very sensitive index of ongoing inflammation,

    • In differentiating between bacterial and viral infections -> very high CRP likely to occur in bacterial than viral infection, and a normal CRP is unlikely in bacterial infection.

    Crp elevation


    Hypersensitivity complications of infections

    Rheumatic feverErythema nodosum leprosum

    Inflammatory disease

    Rheumatoid arthritischronic arthritisAS

    Psoriatic arthritis Systemic vasculitis

    Allograft rejection

    Renal tranplantation






    acute pancratitis




    CRP elevation



    • CRP production in hepatocytes stimulated by IL6

    • Cytokines network can be stimulated by various stimuli (IL-1, TNF…) to stimulate and provide feedback to acute phase protein response

    • Liver failure can affect acute phase protein production

    • Defects in cytokine network also ↓ acute phase protein production

    Seminar in dialysis: 17(6): 438 Nov, 2004

    Prolong pt ptt case report


    • Extra corporeal membrane oxygenator

    • GOAL: to increase tissue oxygenation

    • va was used to bypass pulmonary circulation and pump flow determine the systemic flow perfusion due to poor LVEF

    • vv better: maintain pul blood flow, ↑myocardial oxygenation, keep thrombin or emboli to pul (vs systemic)

    Ecmo setup

    ECMO setup

    Current Opinion in Critical Care 2005, 11:87–93

    Indication ecmo

    Indication ECMO

    • ECMO high-end therapy for respiratory


    • all other treatment options failed to ↑

      tissue oxygenation

    • defined as a PaO2/FiO2 ratio below 50mmHg.

    Current Opinion in Critical Care 2005, 11:87–93

    Contra indication of ecmo

    Contra-indication of ECMO

    • Prolonged mechanical ventilation (>5days)

    • Sepsis

    • Absolute contra-indication to systemic anticoagulant

    Complication of ecmo

    Complication of ECMO

    • Bleeding (surgical & chest tube site)

    Prolong pt ptt case report


    • Intra-aortic balloon pump

    • GOAL: provide hemodynamic support to

    • critically ill patients with cardiac disease.

    • Improvement depend on: volume of balloon, position in aorta, heart rate, rhythm, compliance of aorta, systemic resistance

    Am J Cardiol 2006;97:


    Indication for iabp

    Indication for IABP

    • Hemodynamic support during/after cardiac catherization

    • cardiogenic shock

    • Weaning from cardiopulmonay bypass

    • Pre-op support with severe left main cornary arterial stenosis

    • Adjuct therapy for high risk patients with

      • Complicated angioplasy

      • Restenosis

    Prolong pt ptt case report


    ↑ afterload + suction effect

    ↑ preload

    Contra indication of iabp

    Contra-indication of IABP

    • Aortic regurgitation

    • Aortic dissection/aneurysm

    • uncontrolled septicemia

    • bleeding diathesis

    Complication of iabp

    Complication of IABP

    • Bleeding

    • systemic embolization

    • limb ischemia

    • amputation

    • Infection

    • Balloon rupture




    Causes of prolong pt ptt

    Von Willebrands (lack vWD for platelet adhesion)

    Thrombocytopenia (genetic, bone marrow dz, iron)

    Vit K deficiency

    Mass transfusion (blood lack platelet, factor V)

    Liver disease


    Antiphosplipid syndrome (ab against cell memb)


    A: VIII deficiency

    B: IX deficiency

    Protein C deficiency

    Protein S deficiency

    Antithrombin III deficiency

    Causes of prolong PT, PTT

    POMD 7th ed.

    Prolong pt ptt case report


    Prolong pt ptt case report

    Thank you

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