MISCELLANEOUS SITES OF BLEEDING
MISCELLANEOUS SITES OF BLEEDING: Excerpt from Differential Diagnosis in Primary Care
Bleeding from the ear. This is not usually a serious
condition. Anatomy is again applied to formulate a diagnosis. The
blood may be from the external or middle ear, and usually is caused by
diseases of the skin or drum. Trauma is the most significant cause and is
usually related to self-inflicted lacerations from digging at wax with
hairpins or pencils, for example, which may occasionally rupture the
eardrum. Children are prone to lodge foreign bodies in their ears. Skull
fractures of the posterior fossa may present with bleeding from the ear.
External otitis and otitis media may cause a bloody discharge, but this is
not common. If the drum is ruptured by infection, there is usually bleeding
from the ear. Carcinomas of the skin of the external canal may cause a
bloody discharge, and cholesteatomas will cause bleeding when they ulcerate
through the tympanic membrane. Coagulation disorders rarely present with
bleeding from the ear, in contrast to epistaxis and bleeding from the gums.
Bleeding from the gums. No anatomic breakdown is necessary
here. The causes may be divided into local and systemic categories but, by
using the word VINDICATE, one can cover all the etiologic
categories adequately.
V—Vascular would suggest the
hemorrhagic disorders, especially hemophilia, thrombocytopenia, heparin and
warfarin (Coumadin) therapy, and fibrinogenopenia, as in disseminated
intravascular coagulopathy (DIC).
I—Inflammatory includes acute
gingivitis, dental abscesses, pyorrhea, actinomycosis, or syphilis.
N—Neoplasms suggest both local neoplasms (e.g., odontoma,
papillomas, and epulis) and systemic neoplasms (Hodgkin lymphoma and
leukemia).
D—Degenerative disorders include aplastic anemia and deficiencies
such as scurvy and vitamin K deficiencies.
I—Intoxication recalls mercury, phosphorus, and diphenylhydantoin
intoxication, in which the gums are usually severely hypertrophied as well.
C—Congenital conditions, other than congenital blood dyscrasias
(e.g., sickle cell anemia), include erythema bullosum.
A—Autoimmune suggests
thrombocytopenic purpura, Henoch purpura, and lupus erythematosus.
T—Trauma indicates bleeding from vigorous brushing or picking
with a toothpick.
E—Endocrine disorders are not likely to cause bleeding except
secondarily, as in diabetes-induced pyorrhea or the alveolar bone
degeneration or dysplasia (osteotic) of hyperparathyroidism.
Gingivitis as part of a diffuse stomatitis may be seen in pemphigus,
Stevens–Johnson syndrome, Vincent stomatitis (spirilla and bacilli
fusiformis), and various other bacterial forms. The job of the clinician is
to exclude the systemic causes and then refer the patient to a periodontist
for evaluation and treatment of the local causes.
Bleeding from the breast, hemorrhagic discharge. Suspect a
neoplasm, such as a ductal carcinoma (Paget disease), fibroadenosis, and
ductal papillomas, unless proven otherwise. With a magnifying glass, one may
be able to tell which of the 20 or so ducts is bleeding, but expressing one
small segment at a time, working spirally, is also helpful.
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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RECTAL BLEEDING (Differential Diagnosis in Primary Care)
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