A Bloody Mystery

A CLINICAL PROBLEM-SOLVING article by Adam Cuker from Brigham and Women's Hospital, Boston.
A 62-year-old woman presented to the urgent care clinic with persistent gingival bleeding after periodontal scaling of her lower-right second molar. The patient recalled a similar episode approximately 6 months earlier, also after a periodontal procedure.
A critical first step in narrowing the diagnostic possibilities is to determine whether this patient's hemostatic disorder is hereditary or acquired. The fact that she had undergone significant hemostatic challenges in the past, which includes childbirth and orthopedic surgery, without bleeding complications suggests that the current presentation can be attributed to an acquired bleeding diathesis. The pattern of bleeding also provides important clues. Mucocutaneous bleeding, as is seen in this case, is typical of disorders of primary hemostasis, including thrombocytopenia, qualitative platelet disorders, and von Willebrand's disease.
An Interactive Medical Case associated with this article is available at NEJM.org.[Original Article]