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Approach to a child with

bleeding disorder
Durga

History &Physical
Examination

History of present illness


Question:

Bleeding --- Onset, site,


duration and Age of onset

How did you start to notice that your child has bleedig problem?
Any red spots under skin?
Epistaxis?
Gum bleeding ?
Coffee ground vomiting?
Black tarry stool?
Ask for duration of above symptoms
For intracranial bleed, ask about severe headache and
projectile vomiting

Preceding illness
Question:
Is there any history of fever with rash
before bleeding episode?(ITP)
Associated illnesses
Questions:
Did you notice any pallor in your
child?
Since when?
Was it associated with recent bleeding
In ITP, Pallor is proportionate to amount of
problem?
bledding.But pallor is worse than bleeding in case of
bone marrow failure secondary to aplastic anaemia,

Symptoms of Anaemia/Joint pain,Bone


pain,joint swelling

Questions:
Do you notice tht the child easily gets
tired?Can he/she play like other kids?
Is there any history of
palpitation/dyspnoea on exertion or
recent loss of appetite?
Questions:
Does your child have joint or bone pain?
Does your child have any joint swelling?
Bone and joint pains and swellings are the features of
leukaemias and lymphoma. Haemathrosis of
hemophilia also causes monoarticular joint swelling

Fever
Questions:
Does your child hav any febrile
episode
during
this
period
pallor?
If
Fever can be due to infection in
so,
describe
immunocompromised
patients such as
those with aplastic anaemia,lymphoma
and leukaemia. In lymphoma and
leukaemia,the fever can be due to
malignant condition itself. Fever ie not
a feature in ITP but it can be preceded
by viral infection.

Weight loss and loss of appetite


Question:
Is there any marked weight loss recently?
Does your child have recent loss of appetite?
Loss of appetite and weight are common in
maligancies but it can be due to severe
anaemia itself

Lymphadenopathy
Question:
Does your child have lumps anywhere in the body?
(neck, groin ,abdomen)

Abdominal distention
Questions:
Do you think your childs abdomen
look distended?
It may be due to organomegaly.
Organomegaly and lymphadenopathy
are features of haematological
maligancies

Past Medical History


History of previous illness:
Question:
Did the child have similar problem before?
If present,when,how severe and what were the
treatments?
History of hospitalization
Question:
Was the child admitted to the hospital in the past?
If so, ask when, why, how many time, how long and
what investigations and treatment were done.

Transfusion History
Question:
Has the child been transfused
before?
If so ask total bottle of blood(whole
blood,packed cells or prp),
transfusion interval, use of properly
screened blood(HBV,HIV,HCV,Malaria
and VDRL), any reaction after each
transfusion

Drug History
Question
Is there any regular medication?
If so,what sort of medication he/she
is taking?
Has your child ever taken sulphur
containing
drugs,chloramphenicol,NSAID,anti
epileptic drugs and Herbal medicine?
* causes aplastic anemia

Has your child got radiation exposure in the


past?* known cause aplastic
anaemia,leukaemia and lymphoma
Has he/she been in contact with insectides or
fertilizers?
Is your child taking any regular medications
like steroids or anticancer drugs?
* Steroids are used in ITP, aplastic
anaemia,leukaemia and lymphoma
Are you living in area close to lead industry?

Family History and Social


History
Questions
Are there any similar illness in family
and relatives?
*Common among male relatives
of the mother in hemophilia
Ask the burden of disease in family,
family income and social problems

Physical Examination
Physical examination
offers further clues to
the diagnosis
Is it bleeding?
Look for
Fixed drug eruption
Erythema nodosum
Viral exanthem
Mosquito bites
Presence of petechiae

Ecchymoses
Hematomas
Hemarthroses
Mucous
membrane
bleeding

Disorders of platelet
Clinical findings
(usually have mucous
membrane bleeding)

Disorders of coagulation
Clinical findings
(clotting factor deficiency
such as factor VIII or factor IX
deficiency)

petechiae on the skin and


mucous membranes

deep bleeding into muscles


and joints

small, ecchymotic lesions of


the skin
and multiple

much more extensive


ecchymoses and hematoma
formation.

hematomas

Hemarthrosis

Bleeding from
superficial cuts and
Scratches (often profuse)

Delayed bleeding(common)

Fixed drug
eruption

HEMATOMA

Petechiae
& Purpura

Ecchymose
s

Erythema
nodosum

Viral
exanthem

Mosquito
bites

Hemarthrosis of
elbow joint