INTRODUCTION

Reduced platelet count or function is typically expressed clinically as a bleeding problem; further chapters of this book discuss platelet disorders in more detail. The clinician faced with a patient presenting hemorrhagic symptoms, however, must consider a much broader differential diagnosis than just a platelet problem. The present chapter describes a systematic approach to such a bleeding patient. This involves taking initial urgent measures if required and then performing a brief inspection for subcutaneous bleeding, taking a focused medical history, completing the physical examination, and reviewing the initial laboratory tests.

INITIAL URGENT MEASURES

If the patient is actively bleeding at the moment of presentation, it may be necessary to estimate the extent of blood loss; in the acute phase of hemorrhage, the hemoglobin level will be uninformative; (postural) hypotension or tachycardia are signs of a filling defect of the circulation and the need for fluid replacement. In an actively bleeding patient, it is always appropriate to place a peripheral venous line at the moment of drawing blood. If there is suspicion of an important hemostatic defect, one should avoid puncture of a neck vein or of an artery, since catastrophic hemorrhage can be the consequence, resulting in compression of the airways in the neck (Fig. 9.1) or of the femoral nerve in the groin following arterial blood sampling.