Approach to bleeding disorders (platelet dysfunction) Quiz: Ace Your Exams

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A 62-year-old man presents to the clinic with spontaneous bruising and nosebleeds over the past two weeks. He reports associated fatigue, decreased appetite, and myalgias. He has a past medical history of chronic kidney disease secondary to diabetes mellitus. He has been noncompliant with his medications over the past three weeks and has not been taking any medications. His current medication regimen includes losartan, insulin, and metformin. Vital signs are within normal limits. He has no prior history of recurrent or excessive bleeding or bruising. On examination, he appears pale with scattered ecchymoses over the upper and lower extremities bilaterally. There is dry crusted blood in both nares. Cardiopulmonary examination is within normal limits. There is no hepatosplenomegaly. Laboratory results are shown below. Which of the following mechanisms is the most likely cause of bleeding and bruising in this patient? 

 Laboratory Test      Result     
 Hemoglobin 9.8 g/dL     
 White blood cell count 6,500 /µL     
 Platelets 190,000 /µL     
 Prothrombin time (PT) 13 seconds     
 Activated partial thromboplastin time (aPTT) 35 seconds     
 Blood Urea Nitrogen (BUN) 85 mg/dL     
 Serum Creatinine 5.2 mg/dL (previously 2.0 mg/dL)     
 Glomerular Filtration Rate (GFR) 12 mL/min/1.73 m²     
 Fibrinogen 300 mg/dL     
 D-dimer 0.4 mg/L     

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