Online Case 3-24-11 Thurs

Online Case 3-24-11 Thurs - O nline Case 3/24/11 ASH GI...

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Online Case 3/24/11 – ASH – GI Bleeding I. HISTORY PATIENT PRESENTATION A 51-year-old woman sees her physician because of abdominal cramping and diarrhea. Large amounts of blood are present in her stools. She has a past history of a peptic ulcer and hypertension. The surgeon who is also evaluating her is concerned about the amount of blood in the stool and has asked the referring physician to rule out a coagulopathy. What is your first step in evaluating this patient? Take additional history Correct. COMMENT: Additional history should be obtained and the physician should specifically ask about bleeding history in first-degree relatives as well as in the patient. The family history is important and, if positive, is very helpful in establishing a diagnosis of an inherited bleeding disorder. For example, bleeding in male offspring might suggest hemophilia (x-linked inheritance), whereas bleeding in members of either sex and in every generation of a family might suggest von Willebrand's disease (clinical expression of disorder in heterozygotes). The family history is negative in this patient. Start laboratory tests Not the best choice at this time. Try again. COMMENT: Laboratory tests are neither as sensitive nor as specific as a carefully taken history. As Suchman and Griner have written (Ann Intern Med 1986; 104:810-6): "In screening for coagulation disorders (or increased risk of postoperative hemorrhage), the tests add no information to the preoperative care of patients without clinical findings indicative of increased bleeding risk. Furthermore, the prevalence of asymptomatic congenital coagulopathies is so low that false-positive test results greatly outnumber true-positive results." What should you ask about the current problem? Consider each of these questions and click on the ones that are most relevant to this case. Do her stools contain undigested food particles? Not relevant in this case. Has she had blood in her stools previously? Good choice. PATIENT FINDINGS: No, she has never had this problem before. Has she noticed light stools and dark urine? Although not relevant in this case, it may indicate liver disease as a cause for coagulopathy. What is the duration of her current bleeding problem?
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Good choice. PATIENT FINDINGS: The symptoms of colitis have been present for 3-4 weeks, but the bleeding has been within the past two weeks. What past medical history do you need? Consider each of these questions and click on the ones that are most relevant to this case. Did you have any bleeding problems associated with pregnancies or deliveries? Good choice. PATIENT FINDINGS: She had 5 pregnancies and deliveries without excessive bleeding. COMMENT: Bleeding with pregnancy and delivery that results in anemia or transfusion may lead to a suspicion of a bleeding disorder. Have you ever had back pain?
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This note was uploaded on 09/14/2011 for the course PHARM HEM taught by Professor Staff during the Spring '11 term at UCSD.

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Online Case 3-24-11 Thurs - O nline Case 3/24/11 ASH GI...

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