Continued...

History and clinical examination

The type of bleeding manifestation helps guide the evaluation. Mucosal bleeding (gum bleeds, epistaxis, menorrhagia), petechiae, and bruising (Fig.1) are more typical of quantitative or qualitative platelet disorders and von Willebrand disease (vWD). Conversely, spontaneous deep muscle (Fig.2) and joint bleeding (Fig.3) is seen more commonly with bleeding due to coagulation-factor deficiencies such as in hemophilia.

Fig. 1: Petechiae & Ecchymoses

Family history of the patient is important in the diagnosis of a congenital bleeding disorder. Sometimes, inherited hemorrhagic disorders have gone undiagnosed in families or have been misdiagnosed for multiple generations, especially when mild. Questioning should include all members of the family, regardless of any early suspicions as to the nature of diagnosis. For example hemophilia, an X-linked disorder that primarily affects males may also result in abnormal bleeding symptoms in female carriers. It is important to inquire about previous surgical procedures, dental extractions and transfusions in all family members. The menstrual and obstetric histories of female relatives can throw light on certain bleeding disorders.