History and physical exam
–Personal or family history of bleeding, including bleeding with minor trauma, medications, postsurgical bleeding, menorrhagia, tooth extractions
–Rectal exam and stool guaiac testing for occult GI
bleeding
–Joint exam for hemarthrosis
-
Initial laboratory tests include CBC with peripheral smear, platelet count, PT/INR (evaluates extrinsic pathway—factors X, VII, V, II, I), PTT (evaluates intrinsic pathway—XII, XI, IX, VIII, V, II, I), thrombin time (measures ability of thrombin to transform fibrinogen in fibrin), bleeding time (evaluates platelet function and capillary integrity), and urinalysis (for hematuria)
-
Additional tests may be indicated
–Fibrinogen assay
–Urea clot lysis test (evaluates factor XIII deficiency)
–Mixing studies (determines the presence of an
anticoagulant in the blood)
–Specific factor assays
–Platelet adhesion and aggregation tests (to evaluate
platelet function)
–Bone marrow aspirate (to evaluate platelet production and rule out leukemia) - Hematology consultation is often indicated
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Cesarean birth:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Special tests and monitoring procedures provide early indications of the need for cesarean birth:
❑ Magnetic resonance imaging or clinical pelvimetry reveals CPD and malpresentation.
❑ Ultrasonography shows pelvic masses that interfere with vaginal delivery and fetal position.
❑ Auscultation of fetal heart rate (by fetoscope, Doppler unit, or electronic fetal monitor) determines acute fetal intolerance of labor.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Purpura/Petechiae/Excessive Bleeding:
Differential Overview
(Field Guide to Bedside Diagnosis)
Purpura
❑Trauma
❑Senile purpura
❑Drugs
❑Vasculitis
❑Vitamin K deficiency
❑Psychogenic purpura
❑Cholesterol emboli
❑Warfarin necrosis
❑Scurvy
❑Thrombotic thrombocytopenic purpura
❑Henoch-Schonlein purpura
❑Amyloidosis
Petechiae
❑Autoimmune thrombocytopenia
❑Bacteremia
❑Hypersplenism
Excessive Bleeding
❑Over-anticoagulation
❑Thrombocytopenia
❑von Willebrand disease
❑Circulating anticoagulant
❑Disseminated intravascular coagulation
❑Hemophilia
Diagnostic Approach
A patient with a suspected bleeding disorder should be questioned about response to trauma, past bleeding problems, for example with surgery or dental extractions, history of transfusion, menstrual history and dietary habits. Absence of abnormal bleeding with surgery, significant trauma, or dental extractions makes an inherited bleeding disorder unlikely.
Petechiae are small capillary hemorrhages resulting from platelet or vascular abnormalities. Petechiae on the lower extremities or mucous membranes are usually caused by thrombocytopenia. Tender, elevated petechiae plus abnormalities in other organs suggests vasculitis. Platelet defect disorders produce petechiae and ecchymoses occurring immediately after local trauma. Bleeding is superficial, occurring in the skin, the mucous membranes, the nose, and the gastrointestinal and genitourinary tracts. Bleeding does not occur with normal platelets until the count falls to less than 50,000, and the threshold for important bleeding is 20,000. Oozing blood around catheters suggests DIC, vitamin K deficiency, or platelet abnormalities.
Large-area bruising occurs with vitamin-K–dependent factor deficiency, but not with hemophilia. Plasma protein disorders produce bleeding in deep tissues, such as joints, muscle, and retroperitoneum. The onset of such bleeding can be delayed for hours after trauma.
Palpable purpura is seen with autoimmune or infectious (e.g., meningococcemia, endocarditis) vasculitis. Infectious emboli have an irregular outline, whereas lesions of leukocytoclastic vasculitis are circular.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
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