Excessive Bleeding or Clotting (Case 28)

When I encounter a patient with bleeding, the most important approach is to take a detailed history and perform a physical examination. First, I like to establish whether the bleeding disorder is of a chronic nature. Is this a condition the patient had all of his or her life, and do I have to think about congenital causes (such as hemophilia or von Willebrand’s disease), or is this of recent onset and more likely an “acquired” condition?

If the problem seems to have been going on for a significant portion of the patient’s life, it is crucial to get a good family history of any family member with bleeding tendencies and to draw a pedigree to establish the inheritance pattern.

If the bleeding is of more recent onset, it is critical to elicit any changes in the patient’s life that may have been contributory, such as new medications, newly diagnosed other medical conditions, other associated symptoms, and recent travel.

Finally, it is important to separate disorders of primary hemostasis from disorders of secondary hemostasis. Patients with primary hemostatic disorders usually present with superficial bleeding such as easy bruisability, gum bleeding, or menorrhagia; the primary hemostatic system involves platelets, von Willebrand factor, and a vessel wall. Patients with disorders of secondary hemostasis, such as factor deficiencies, usually present with deep bleeding such as cerebral hemorrhage or bleeding into muscles and joints.