Question

1. What findings from the patient history, physical examination, or lab studies would indicate a possible bleeding disorder?

Answer 1

ANSWER: Bleeding disorders are a group of disorders that share the inability to form a proper blood clot. They are characterized by extended bleeding after injury, surgery, trauma or menstruation. Sometimes the bleeding is spontaneous, without a known or identifiable cause. Improper clotting can be caused by defects in blood components such as platelets and/or clotting proteins, also called clotting factors.

FINDINGS FROM HISTORY AND PHYSICAL EXAMINATION INDICATES BLEEDING DISORDER:

• distinguish between primary and secondary hemostatic disorders and to determine whether the disorder is inherited or acquired.
• Epistaxis is common in individuals with primary hemostatic disorders, but it is also common in healthy individuals. Details about the frequency, duration, packing requirement, and previous treatment (cautery or transfusion) are helpful for assessing the severity of bleeding.
• Bleeding gums is a common symptom in persons with primary disorders of hemostasis. The bleeding could be spontaneous or it could be associated with brushing or flossing.
• Hemoptysis, hematemesis, hematuria, hematochezia, and melena are rarely the initial symptoms of a bleeding disorder
• Menstrual history is important. Metromenorrhagia is often observed in women with primary hemostatic disorders. This is especially common in those with von Willebrand disease
• Bleeding in the joints is the hallmark of hemophilia and other secondary hemostatic disorders.
• In males, excessive bleeding following circumcision is often the initial manifestation of a congenital bleeding disorder.
• Delayed bleeding from the umbilical stump is characteristic of a factor XIII deficiency.
• Bruising is common in individuals with a platelet disorder. A careful physical examination often reveals signs of a hemostatic disorder
• Petechiae are pinpoint hemorrhages (< 2 mm) in the skin, and purpura (0.2-1 cm) and ecchymoses are larger hemorrhages
• mucocutaneous bleeding suggest that the underlying condition is caused by platelet dysfunction, whereas hemarthroses or hematomas are more common in coagulopathy.
• Anemia, neurologic abnormalities (aphasia, hemiplegia, mental status changes, seizures, paresthesia, visual disturbance, renal dysfunction)
• Blood transfusion reaction, infection, malignancy, pancreatitis, pregnancy (preeclampsia, acute postpartum hemorrhage, septic abortion) can be sign of DIC.

ABNORMAL LAD FINDINGS THAT INDICATES BLEEDING DISORDER:

• Five studies are important to the diagnosis of bleeding disorders: bleeding time (BT) (Simplate), platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), and thrombin time (TT).
• Von Willebrand disease, a disorder of platelet aggregation, is the most common cause of inherited coagulopathies. Thus, if the PT and PTT are normal, the next step is testing for von Willebrand factor antigen, von Willebrand factor activity (also called ristocetin cofactor activity), and factor VIII level
• A prolonged PTT with a normal PT indicates an abnormality in the intrinsic pathway.
• If the platelet count alone is low, the cause is usually peripheral destruction of platelets, immunothrombocytopenia, or an abnormality of bone marrow production.
• When the aPTT is the only abnormal test and the patient has a definite history of bleeding, one of the hemophiliac states is present.
• An abnormal PT, with or without an abnormal aPTT but with normal results in the other three tests, indicates an abnormal reduction in the vitamin K-dependent clotting factors (II, VII, IX, X) or factor V.
• When the TT is abnormal, disseminated intravascular coagulation, the presence of plasma heparin, or a hepatopathy should be suspected
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