EVALUATION OF A BLEEDING TENDENCY
A clinically important bleeding tendency may result from defects in the blood vessels, the platelets, or the coagulation proteins. The defects may be qualitative or quantitative, and single or multiple. Inherited hemorrhagic disorders tend to result from single defects, whereas acquired disorders result from single or multiple deficiencies. Evaluation of a patient for a bleeding tendency is needed in three settings: (1) screening prior to surgery, (2) when prior episodes of spontaneous or traumatic bleeding are reported, and (3) during active bleeding unresponsive to simple measures The personal and family history is essential in evaluation of a bleeding tendency. A positive family history of bleeding in males suggests one of the hemophilias, which make up 95 per cent of congenital coagulation deficiencies. Spontaneous bleeding or bruising or easy bruising and bleeding after minor trauma are important, especially if bruises are large or raised (hematomas). Excessive bleeding after prior surgery or dental extraction, events that stress the hemostatic process, may indicate a bleeding tendency in persons without spontaneous bleeding history. A history of monorrhagia or peripartum hemorrhage in a woman can also signify an underlying bleeding diathesis.
If bleeding has occurred, its timing, location, and clinical setting provide key clues to the type of defect. In platelet disorders, bleeding tends to be immediate and transient and involves mucous membranes or skin (e.g., epistaxes or bruising). In contrast, delayed bleeding after trauma or surgery, or bleeding into joints or muscles, is typical of coagulation disorders. The presence of systemic diseases such as liver disease, hematologic malignancy, or uremia may impair hemostasis. Drug ingestion is the single most common cause for acquired hemostatic defects; a careful drug history should include direct questioning about ingestion of aspirin, nonsteroidal anti-inflammatory compounds, antibiotics, and anticoagulants as well as alcohol. All of these substances can cause bleeding or exacerbate an underlying bleeding disorder, as can profound nutritional impairment. Some specific bleeding disorders to be considered from the patient’s history are listed in .
Pertinent aspects of the physical examination in evaluating possible bleeding disorders include examination of the skin, mucous membranes, and retina for petechiae, ecchymoses, or hematomas and examination of the abdomen for hepatosple-nomegaly. Petechiae are pinpoint hemorrhages from microvessels in the skin and are associated with platelet disorders or thrombocytopenia. Because pressure can exacerbate petechial bleeding, these lesions are commonly found on the legs or in other areas of increased hydrostatic pressure (e.g., on the buttocks in a bedridden patient). Purpura (confluent petechiae) are also common in thrombocytopenia. Ecchymoses, especially if spontaneous or raised (hematomas), and hemar-throses suggest defects in plasma coagulation factors as in hemophilia. Hepatomegaly suggests liver disease, and splenomegaly is associated with thrombocytopenia or with hematologic malignancy.