Chapter 059. Bleeding and Thrombosis (Part 4)

Approach to the Patient: Bleeding and ThrombosisClinical Presentation Disorders of hemostasis may be either inherited or acquired. A detailed personal and family history is key in determining the chronicity of symptoms and the likelihood of the disorder being inherited and it provides clues to underlying conditions that have contributed to the bleeding or thrombotic state. In addition, the history can give clues as to the etiology by determining (1) the bleeding (mucosal and/or joint) or thrombosis (arterial and/or venous) site, and (2) whether an underlying bleeding or clotting tendency was enhanced by another medical condition or the introduction of...
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Chapter 059. Bleeding and Thrombosis (Part 4) Chapter 059. Bleeding and Thrombosis (Part 4) Approach to the Patient: Bleeding and Thrombosis Clinical Presentation Disorders of hemostasis may be either inherited or acquired. A detailedpersonal and family history is key in determining the chronicity of symptoms andthe likelihood of the disorder being inherited and it provides clues to underlyingconditions that have contributed to the bleeding or thrombotic state. In addition,the history can give clues as to the etiology by determining (1) the bleeding(mucosal and/or joint) or thrombosis (arterial and/or venous) site, and (2) whetheran underlying bleeding or clotting tendency was enhanced by another medicalcondition or the introduction of medications or dietary supplements. History of Bleeding A history of bleeding is the most important predictor of bleeding risk. Inevaluating a patient for a bleeding disorder, a history of at-risk situations,including the response to past surgeries, should be assessed. Does the patient havea history of spontaneous or trauma/surgery-induced bleeding? Spontaneoushemarthroses are a hallmark of moderate and severe factors VIII and IX deficiencyand, in rare circumstances, of other clotting factor deficiencies. Mucosal bleedingsymptoms are more suggestive of underlying platelet disorders or von Willebranddisease (vWD), termed disorders of primary hemostasis or platelet plugformation. Disorders affecting primary hemostasis are shown in Table 59-1. Table 59-1 Primary Hemostatic (Platelet Plug) Disorders Defects of Platelet Adhesion von Willebrand disease Bernard-Soulier syndrome (absence of dysfunction of GpIb-IX-V) Defects of Platelet Aggregation Glanzmanns thrombasthenia (absence or dysfunction of GpIIbIIIa) AfibrinogenemiaDefects of Platelet Secretion Decreased cyclooxygenase activity Drug-induced (aspirin, nonsteroidal anti-inflammatory agents) Inherited Granule storage pool defects Inherited Acquired Nonspecific drug effects Uremia Platelet coating (e.g., paraprotein, penicillin) Defect of platelet coagulant activity Scotts syndrome The development of bruises (ecchymoses) after trauma is normal; however,an exaggerated response to trauma may be an indication of an underlying bleedingdisorder. Ecchymoses presenting without known trauma, particularly on the trunk,and especially large ecchymoses, >2 in. in diameter, may be a sign of anunderlying bleeding disorder. The introduction of medications or nutritionalsupplements with platelet inhibitory activity often enhance bruising and bleedingin a patient with an underlying bleeding disorder. Easy bruising can also be a signof medical conditions in which there is no identifiable coagulopathy; instead, theconditions are caused by an abnormality of blood vessels or their supportingtissues. In Ehlers-Danlos syndrome there may be posttraumatic bleeding and ahistory of joint hyperextensibility. Cushings syndrome, chronic steroid use, andaging result in changes in skin and subcutaneous tissue, and subcutaneousbleeding occurs in response to minor trauma. The latter has been termed senilepurpura.