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Online Cases 3-25-11 Fri

Online Cases 3-25-11 Fri - Online Cases Friday ASH Bleeding...

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Online Cases 3-25-11 Friday - ASH Bleeding History in a Child Undergoing Surgery I. HISTORY Patient Presentation A 10-year-old Caucasian male is to undergo an elective tonsillectomy. The pre-operative history describes significant bleeding after a recent tooth extraction. The mother reports that the bleeding occurred several hours after the tooth extraction, after they had returned home from the dentist’s office. What additional questions regarding the patient’s history would be important to determine if the patient has an underlying coagulopathy? Is there a history of bleeding after surgery or injuries? Good choice! COMMENT: Patients with a bleeding disorder often give a history of prior bleeding after minor trauma or surgery. In fact, the absence of bleeding in these situations makes significant coagulation disorders unlikely. PATIENT RESPONSE: The patient and his mother report that he has not had any other previous surgery or trauma. They report only what they perceived to be excessive bleeding after a recent tooth extraction as described earlier. The mother also recalls that her son may have had increased bleeding after his circumcision. Does the patient suffer from recurrent infections? Not relevant in this case. COMMENT: Although there are acquired disorders of the bone marrow where platelets are low, which can lead to bleeding symptoms, recurrent infections are more likely to signal abnormalities in white blood cell number or function. This is not the usual presentation for patients with a coagulopathy, and it was not an issue with this patient. Was he taking any medication at the time of his dental extraction, and is he taking any now? Good choice! COMMENT: Although he is young and less likely to be on significant medications, there are many over- the-counter drugs, including aspirin and NSAIDs, and prescription medications such as clopidogrel that can affect platelet function. It would be important to know the relationship of these medications to the timing of the bleeding symptoms. PATIENT RESPONSE: The patient and his mother denied that he had recently taken any prescription or over-the-counter medication. Is there a family history of bleeding disorders? Good choice! COMMENT: This is an essential part of the history since most of the significant bleeding disorders are inherited and may affect several family members. One should ask not only about close relatives but also about males and females on both sides of the family. Particular attention should also be paid to ethnic
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groups with an increased incidence of coagulation disorders, for example, Ashkenazi Jews and Factor XI deficiency. PATIENT RESPONSE: He has a cousin with a bleeding disorder who is under the care of a hematologist. Is there a history of significant weight loss?
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Online Cases 3-25-11 Fri - Online Cases Friday ASH Bleeding...

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