Physical exam

The following describes this patient’s physical exam when you see him in the emergency room:

General appearance: In distress from arm discomfort and worry

Vital signs: Heart rate 97/min, blood pressure 135/89 mmHg, respiratory rate 13/min, T 98oF

Head and neck: No lymphadenopathy

Chest: Normal to inspection, palpation, percussion, and auscultation

CVS: S1, S2, no extra heart sounds, no murmurs

Abdomen: Soft, non-tender, no hepatosplenomegaly

CNS: No focal changes

Upper extremities: Swollen and tense bilaterally throughout upper extremities, with extensive bruising, edema and discolored grey fingers





Example of upper extremity hematoma that resembled the patient’s findings.

This type of bleeding is most typical of:

a
Primary hemostasis
Primary hemostasis includes disorders of platelets and the blood vessel wall. Defects in primary hemostasis are associated primarily with mucocutaneus bleeding. This patient certainly has ecchymoses (bruising), but he also has bleeding in deeper tissue planes, possibly even in muscle. The latter is not typical of a defect in primary hemostasis.
b
Secondary hemostasis
Secondary hemostasis refers to the protein response of coagulation (as distinct from the cellular [platelet] response). Defects in secondary hemostasis are often associated with deep tissue bleeding as seen in this case.

ER, emergency room

Orthopedic consult

Findings:

Assessment:

“Given that this is not acute, and its been going on for 5 days at least, I do not think that acute compartment releases would be beneficial for him.”