Clinical Vignette IX

• Which of the following is the most appropriate next step in management of this patient?

A 51-year-old male is evaluated in the Medtigo Medical Clinic for spontaneous recurring episodes of atraumatic nose bleeds, frequent easy bruising, prolonged bleeding after minor cuts, and an episode of excessive bleeding after a dental extraction one week ago. The patient reports the spontaneous recurring nose bleeds, easy bruising, and prolonged bleeding began about two years ago and has gradually become worse and more frequent. He states the frequent nose bleeds, easy bruising, and prolonged bleeding after minor cuts were minor inconveniences which he attributed to getting older until his dentist strongly recommended that he should see a physician after the recent dental extraction and excessive bleeding episode a week ago. The patient has had some nose bleeds and bruises throughout his life but they were uncommon and when they did occur, it was almost always caused by some form of moderate-to-severe direct physical trauma such as when he used to compete in high-level Brazilian Jiu-Jitsu tournaments. Furthermore, he has had multiple dental extractions throughout his life but none of the procedures were associated with excessive bleeding with the exception of the isolated incident one week ago. To best of his knowledge, he has no blood-related family relatives with any similar bleeding issues. He reports being diagnosed with “some form of congenital heart valve condition as a young child” which he claims to be “no big deal” and has not seen either a cardiologist in over 15 years or any other physician in over 6 years. He admits experiencing some increasing difficulty in completing his daily five mile run over the past year or so due to worsening of his ability to “catch his breath”. Upon further questioning, the patient divulges occasionally seeing some bright red blood in his stool but has yet to seek any medical care about the issue since the blood in the stool seems to spontaneously resolve and does not occur often. The patient does not consume alcohol, smoke, chew tobacco, or use recreational drugs. The takes no prescribed medications. The rest of the patient’s medical history, family history, and social history is non-contributory.

On physical examination, vital signs are normal. Oxygenation saturation is 97% breathing ambient air. Body mass index is 22.7 kg/m². Cardiac examination reveals a harsh systolic ejection murmur in the right second intercostal space which radiates to the neck, a paradoxically split S₂, a left-sided S₄, and a palpable thrill. The remainder of the physical examination is unremarkable. Initial lab and imaging workup performed in the clinic reveals the following: 

12-lead electrocardiogram shows normal sinus rhythm and voltage criteria consistent with left ventricular hypertrophy.

PA/Lateral view chest x-ray shows post-stenotic dilation of the ascending aorta, calcification of the aortic valve, and a prominent left ventricle.

Fecal occult blood test is (+) for trace amounts of heme.

Given the findings of the cardiac TTE, history of present illness, medical history, and physical exam findings, which of the following five lab tests would be most appropriate for the next step in management of this patient? (Select FIVE options)

The transthoracic echocardiographic imaging study reveals the following:

Cardiac Echo Findings                                                             Reference Range

Aortic valve is bicuspid                                                                           —

Aortic cusps thickened and calcified with                                           —

moderately restricted leaflet motion                                                  

Moderate-to-severe aortic stenosis is present                                    —

Aortic valve area of 0.70 cm²                                                         2.5 – 3.5 cm²

Mean pressure gradient of 45.3 mm Hg                                      0.0 – 10.0 mm Hg

Maximum jet velocity of 4.7 m/s                                                  1.0 m/s

Estimated LVEF is 50% +/- 5%                                                    55% – 75%

Concentric LVH is present                                                                     —

Given the results of the lab tests and imaging findings thus far, which of the following three lab tests would be most appropriate for the next step in management of this patient? (Select THREE options)

• The results of the five lab tests reveal the following:

Given the patient’s history of present illness, medical history, clinical exam findings, family history, and all the available lab testing and imaging study results performed thus far, which of the following is the most likely diagnosis?

• The results of the three lab tests reveal the following:

Platelet Function Assay-100 Test

Aggregometry Assay Response Test

Molecular-Weight vWF Multimer Assay

• Provided the correct diagnosis is made, which of the following is the most appropriate next step in management of this patient’s medical condition?

• Now that the patient has been correctly diagnosed and properly managed for his new medical condition, which of the following is the most appropriate next step in management of this patient’s overall health?