Bl Week 2 Pbl Objective 2

Front 1

What are the 4 main areas that must be covered in the history of a patient with a bleeding problem?

Back 1

1. Details about bleeding episode.
2. Past medical history related to bleeding.
3. Medications.
4. Family medical history related to bleeding.

Front 2

What are some important questions to ask about the current bleeding episode?

Back 2

1. When did the bleeding start?
2. How long did it last?
3. How much blood is the patient losing?
4. What sort of trauma (if any) initiated the bleeding?
5. Are there symptoms of anemia following the blood loss?
6. Is it accompanied by any other bleeding or bruising?
7. If there are bruises, how large are they?
8. Are there any other current changes in the patient's health? fatigue? infection? pain? which might suggest a cause of bleeding?

Front 3

What are common symptoms of anemia to ask about?

Back 3

1. Fatigue
2. Shortness of breath on exertion
3. tachycardia
4. pallor

Front 4

What are important questions to ask regarding past medical history?

Back 4

1. Previous episodes of bleeding: epistaxis, hemarthrosis, melena, etc.
2. What is the menstrual history?
3. Have their been any previous bleeding challenges, eg. surgery, dental work?
4. Any post-partum hemorrhage?
5. Any medical conditions (renal and liver dysfunction can lead to abnormal bleeding)?
6. Bruise easily? (may not be that useful as many people without bleeding disorders bruise easily)

Front 5

Which are some important medications to ask about in a patient with a bleeding problem?

Back 5

1. ASA
2. NSAIDS
3. Warfarin
4. Herbal supplements such as garlic and ginko biloba have platelet inhibition

Front 6

What are some important questions to ask about family medical history?

Back 6

1. Is there a history of bleeding in the family?
2. Does a family member have a bleeding disorder dx?
3. Has anyone in the family ever required a transfusion?
4. Has anyone ever died from a hemorrhage?
5. Have family members had bleeding challenges following surgery or dental work?

Front 7

What are the 2 areas of focus of the physical exam in a patient with a bleeding problem?

Back 7

1. Evidence of recent abnormal bleeding.
2. Evidence of a disease which may have secondary bleeding complications.

Front 8

What do you examine for evidence of recent abnormal bleeding?

Back 8

1. Site of hemorrhage
2. Mouth - looking for evidence of mucosal bleeding
3. Skin - are there petechiae, purpura, ecchymoses? Is there pallor?
4. Joints - is there hemarthrosis?
5. Vitals - Is the patient hypotensive or tachycardic?

Front 9

What sorts of skin and mouth findings may indicate platelet-type bleeding?

Back 9

Classic 2 indicators:
1. petechiae
2. mucosal surface bleeing

Front 10

What sorts of skin and mouth findings may indicate factor-type bleeding?

Back 10

1. Hemarthroses
2. Deep tissue hematomas

Front 11

What do you examine for evidence of secondary bleeding complications?

Back 11

1. Signs of liver failure
2. Signs of kidney failure

Front 12

What are some common signs of liver failure?

Back 12

-jaundice
-hepatosplemomegaly
-ascites
-palmar erythema
-spider angiomas, etc.

Front 13

What are some common signs of renal failure?

Back 13

-CHF manifesting as dyspnea,
-edema
-neurologic changes
-itching
-changes in urination

Front 14

How does liver failure lead to a bleeding disorder?

Back 14

1. unable to produce clotting factors
2. unable to gamma-carboxylate Vit K dependent clotting factors
3. unable to produce thrombopoietin for platelet synthesis
4. portal HTN leads to increased destruction of platelets (and RBC's) in the spleen

Front 15

How does renal failure lead to a bleeding disorder?

Back 15

1. Bleeding with purpura, GI and uterine bleeds occurs in 30-50% of patients with chronic renal disease but is out of proportion to degree of thrombocytopenia - thought to be associated with abnormal platelet and vascular function
2. (Most patients with CKD have normochromic anemia due to decreased production of erythropoietin)