Bleeding child: diagnostic approach: Viva

Opening question

What is your diagnostic approach to this girl, and what is the single most important thing you would do before ordering any laboratory tests? ^[5]

This girl has abnormal bleeding: heavy menstrual bleeding from menarche with flooding, clots, and iron deficiency, plus a lifelong history of epistaxis and easy bruising. This is a primary-hemostasis (platelet-type) pattern, immediate and mucocutaneous, with a normal platelet count. Before any laboratory test, the single most important step is to quantify the bleeding history with a validated bleeding assessment tool, because it confirms the bleeding is abnormal and distinguishes a bleeding disorder from normal childhood bruising far better than impression. I would also take a careful family history, because heavy menstrual bleeding is the commonest presentation of Von Willebrand disease and the inherited platelet function disorders in females. ^[5]