Never take your eyes off of a bleeding patient

“Please help me. I was brushing my teeth this morning and started bleeding a ton from my mouth.”

Joe (identifying information changed) pointed to a bucket next to his bed. I was horrified to see close to two pints of blood in it.

With gloves on, I pulled out my penlight and a new tongue depressor.

“Open your mouth wide for me Joe. I need to see where you are bleeding from.”

I clicked the light on and with my other hand started exploring around his upper and lower gums. I lightly pressed various areas inside his mouth with no bleeding. There were no mucosal lesions either. I only saw dried blood over his teeth and oral cavity. I couldn’t find any signs of the source.

“Is this the first time you’ve bled like this?”

“First time, sir.”

“Any history of bruising?”

“No, sir.”

“It looks like you do have some small bruises on your arms over here.”

“Oh, those? I didn’t notice, but yea those weren’t there before.”

“Do you have any family members with bleeding problems?”

“Nah, my parents are pretty healthy. So are my brother and younger sis. Actually, sorry, my dad mentioned to me once that he had gum bleeding. But I’m not exactly sure.”

Possibilities were running through my head: hemophilia, scurvy, von Willebrand disease, maybe one of the platelet function disorders. I took more of Joe’s history and completed the physical exam.

“Were you given any medications since coming here?”

“One of the nurses gave me a mouthwash to use; she said it would help stop the bleeding.”

“And you haven’t bled since using the mouthwash?”

“Not since, thank God.”

“I think I have everything for now, Joe. I’ll be back soon with my boss.”

“Please don’t go, sir. It’s just me here.”

We were in the last ER bed next to the emergency door. Joe was a 12-year-old Hispanic boy who loves playing basketball (and supposedly has handles like Kyrie Irving).

“Are your parents coming to visit you later today?”

“My mom just left to go back to work. I haven’t heard back from my dad yet.”

“They’ll be here as soon as they can.”

“I hope so…”

As I was saying goodbye to Joe, my attending tapped me on the shoulder.

“Looks like you both were having a good conversation!”

“Oh hey, Dr. Scott! Yes, this is Joe. May I present him to you?”

“Have at it.”

“OK, so Joe is a 12-year-old Hispanic male who comes in with acute onset oral bleeding. While brushing his teeth this morning, he started to bleed profusely into the sink. His mom immediately took him here and since arrival has bled two pints of blood. Oral cavity exam is unremarkable; I was unable to locate the source of bleeding. There are some small bruises on his upper arms, but otherwise negative physical exam. He denies any trauma, bleeding elsewhere, shortness of breath, chest pain, trouble swallowing, choking or other symptoms. No past medical history of easy bruising or similar bleeding episodes. He mentioned that his dad had gum bleeding in the past. No smoking, drinking, or illicit drug history. Joe doesn’t take any medications and is otherwise active and eats a balanced diet.”

“Good, thank you, T.J. Hey, Joe, how are you feeling buddy?”

“I’m feeling OK, sir.”

“Is it OK if I also examine you? I’ll be doing what T.J. just did.”

“That’s OK with me, sir.”

Dr. Scott did a thorough physical exam, also checking Joe’s feet, scalp, and ears.

“I’m sorry about your bleeding, but since this is the first time it’s happened to you, it may be because you were brushing your teeth too hard.”

“My mom tells me that every day.”

“Listen to your mom; I think you’ll be just fine. Any questions for us, Joe?”

“I don’t think so … does that mean I get to go back to school?”

“If your mom or dad can pick you up, yes, we’ll wrap things up and get you on your way.”

Joe looked like a million bucks and was ready to leave the ER. Though, I had serious doubts about him leaving so soon. Maybe it was looking at the blood bucket several times or his story of the sheer amount of bleeding that happened in the morning. I told myself there must be a medical reason for Joe’s bleeding, and I asked my attending for us to admit Joe to the inpatient floor for overnight observation as we run some tests (including an iron panel, ascorbic acid, and coagulation studies).

“You want us to admit him to the floor instead of discharge?”

“I feel that strongly yes, it would give more assurance to Joe and his parents. Also, he did have some very subtle bruises on his arms and mentioned that his dad had bleeding gums.”

“Alright, sounds like appropriate reasoning to me. I will admit him for observation in a few minutes, let me know if something changes with his condition.”

“Thank you, Dr. Scott.”

The remainder of the day was uneventful, and Joe was doing quite well, but as he was eating his dinner, the bleeding returned in full force.

My attending and I rushed to the ER bay as soon as we got the call. People were surrounded around Joe’s bed and were checking his vital signs and mental status. Joe had his head down and was sitting upright holding a bucket in his hands. Bloodied bed sheets being changed out for new ones.

“Joe! Are you OK?”

“Oh hey, T.J. I started to bleed again while eating my sandwich. I’m sorry for making a mess …”

“Don’t be sorry. We are here for you. I called your parents earlier, and they will be here soon. You’ll stay overnight upstairs, but we’ll keep a close eye on you and make sure that everything is OK.”

Dr. Scott consulted hematology as I spoke with Joe and within the hour he was transferred to their service.

What was the final diagnosis?


Ton La, Jr. is a medical student and student editor, The New Physician.

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