Continued...

History and clinical examination

History of drug ingestion is crucial as results of tests may be misleading and wrong diagnosis may be made. Non-steroidal anti-inflammatory drugs such as ibuprofen, mefenamic acid, etc. and aspirin inhibit platelet function whereas anticonvulsants, antihistaminics, antituberculous drugs especially rifampicin are known to cause thrombocytopenia.

Fig 2 - Deep muscle bleed

Fig 3: Joint Bleed (Hemarthrosis)

The overall health of the patient also is a clue to the cause of bleeding. Congenital bleeding disorders and ITP usually occur in children who are otherwise well. Conversely, disseminated intravascular coagulation (DIC) occurs in sick individuals with co-morbid conditions. Liver disease often is associated with bleeding due to impaired production of coagulation factors and renal disease is often associated with abnormalities in platelet function, thereby leading to defects in primary hemostasis.

Physical examination offers further clues to the diagnosis. Petechiae are pathognomonic of platelet-related bleeding, and mucus membrane bleeds (Fig.4) may also be present. Ecchymoses in places other than the anterior shins and elbows, such as the flank, abdomen, or back, may be indicative of a bleeding propensity. Bruises in any area that appear excessively large for the degree of trauma or those with underlying palpable hematomas may be seen in patients with significant bleeding disorders. Swelling of any joint without a history of significant trauma is definitely abnormal. Similarly, deep tissue and intramuscular bleeds should prompt the diagnosis of a coagulation factor deficiency. However, the possibility of physical abuse must be considered in the evaluation of any child with unusual patterns of bruising or bleeding.

Fig 4: Mucous membrane bleed - subconjunctival, periorbital & gum bleed