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EVALUATION OF A SUSPECTED BLEEDING DISORDER

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History

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  • A systematic approach is required to elicit and interpret all relevant information. Extensive, direct discussion between physician and patient is necessary to uncover the sometimes subtle details pertinent to a history of bleeding.

  • Many otherwise healthy individuals, more often women than men, will report easy bruising and/or excessive bleeding.

  • Patients with severe hemorrhagic disorders invariably have significantly abnormal histories of bleeding, either spontaneous or after trauma and/or interventions (eg, biopsies or surgical procedures).

  • Typical clinical manifestations occur with specific hemostatic disorders, as outlined in Table 72–1.

  • When evaluating the absence of prior bleeding, it is important to determine whether or not the patient has been exposed to significant hemostatic challenges, such as dental extraction, surgery, trauma, or childbirth.

  • It is also important to attempt to obtain objective confirmation of the bleeding event and the severity, such as the need for blood transfusions, the development of anemia requiring iron replacement, hospitalization because of bleeding, ambulatory evaluation of a bleeding tendency, and the results of any laboratory studies done previously.

  • A medication history is essential, with particular attention to nonprescription drugs (eg, aspirin or nonsteroidal anti-inflammatory drugs, or NSAIDs) and other drugs taken regularly and therefore easily forgotten, including herbal and other alternative medicines.

  • A nutritional history is necessary to evaluate intake of vitamin K, vitamin C, and the adequacy of general nutrition.

  • A history of bleeding involving one organ or system, such as hematuria, hematemesis, or hemoptysis suggests a local cause, such as a neoplasm. Bleeding from multiple sites may indicate a coagulation defect.

  • Prolonged oozing of blood from sites of high fibrinolytic activity, such as the urinary tract, endometrium, or oral and nasal mucosa, may occur in patients with hemostatic abnormalities.

  • Mucosal and cutaneous bleeding may also be caused by vascular disorders, such as hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome) or scurvy (see Chap. 77).

  • A detailed family history is particularly important, including all relatives going back at least one generation and specific inquiry about any consanguinity.

  • A history of some bleeding problems may be suggestive of specific disorders.

  • Epistaxis and gingival hemorrhage are the most common symptom of qualitative or quantitative platelet disorders, von Willebrand disease, and hereditary hemorrhagic telangiectasia.

  • Cutaneous bruising may occur with a variety of hemostatic disorders.

  • The frequency, size, location, color, and history of trauma are all relevant to evaluating the significance of the bruising.

  • Dental extractions present severe hemostatic challenges that can be objectively evaluated by the need for suturing, packing, or transfusion.

  • Prolonged bleeding from razor cuts inflicted while shaving often occur in patients with platelet disorders or von Willebrand disease.

  • Hemoptysis, hematemesis, or hematuria is rarely the presenting symptom in patients with bleeding disorders.

  • In patients who also have a local lesion, bleeding disorders may contribute to repeated episodes of hematochezia or melena.

  • Menorrhagia occurs with platelet disorders and von Willebrand disease, but most often is not associated with a bleeding disorder.

  • Excessive ...

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