Which features of the history and physical exam are associated with platelet disorders?

Updated: Nov 30, 2019
  • Author: Perumal Thiagarajan, MD; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP  more...
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History and physical examination findings help clinicians to distinguish between primary and secondary hemostatic disorders and to determine whether the disorder is inherited or acquired.

Epistaxis is common in individuals with primary hemostatic disorders, but it is also common in healthy individuals. Details about the frequency, duration, packing requirement, and previous treatment (cautery or transfusion) are helpful for assessing the severity of bleeding (see also the Medscape Reference articles Anterior Epistaxis Nasal Pack and Posterior Epistaxis Nasal Pack).

Bleeding gums is a common symptom in persons with primary disorders of hemostasis. The bleeding could be spontaneous or it could be associated with brushing or flossing. Bleeding from tooth extractions is possible. A molar tooth extraction is a traumatic procedure. Uneventful extraction of a molar is unlikely in a patient with a severe bleeding disorder.

Hemoptysis, hematemesis, hematuria, hematochezia, and melena are rarely the initial symptoms of a bleeding disorder. However, these may be exacerbated by an underlying bleeding disorder.

Menstrual history is important. Metromenorrhagia is often observed in women with primary hemostatic disorders. This is especially common in those with von Willebrand disease and is often exacerbated by the NSAIDs used to treat dysmenorrhea. Bleeding after childbirth may be the first manifestation of a mild bleeding disorder.

Bleeding in the joints is the hallmark of hemophilia and other secondary hemostatic disorders. Details of previous surgeries, including the amount of blood transfused, if any, are helpful.

In males, excessive bleeding following circumcision is often the initial manifestation of a congenital bleeding disorder. Delayed bleeding from the umbilical stump is characteristic of a factor XIII deficiency.

Defective wound healing is observed in individuals with a factor XIII deficiency and abnormal fibrinogens. Medication history findings may be helpful because aspirin often accentuates a preexisting bleeding disorder. A history of previous iron therapy for anemia may be useful.

Physical examination

Bruising is common in individuals with a platelet disorder. A careful physical examination often reveals signs of a hemostatic disorder (see image below).

Purpuric spots. Purpuric spots.

Petechiae are pinpoint hemorrhages (< 2 mm) in the skin, and purpura (0.2-1 cm) and ecchymoses are larger hemorrhages. The purpura is not palpable, in contrast to the palpable and sometimes tender purpura observed in patients with vasculitis (see image below).

Vasculitis in childhood. Vasculitis in childhood.

Initially, purpura tends to form in the areas of increased venous pressure, such as the legs. Petechiae and purpura may develop following the application of a sphygmomanometer cuff.

Splenomegaly is not observed in the typical patient with ITP. The spleen can engulf platelets and be several times normal size without becoming palpably enlarged.

Hemarthrosis and deep muscle hematomas are unusual in patients with primary hemostatic disorders.

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