From the Guidelines
The initial workup for a patient presenting with easy bruising should begin with a thorough history and physical examination, followed by laboratory testing, as this approach helps identify the underlying cause of bruising and guides further management.
Initial Evaluation
The history should focus on medication use (especially anticoagulants, aspirin, NSAIDs), family history of bleeding disorders, timing and pattern of bruising, and associated symptoms like heavy menstrual bleeding or gum bleeding 1.
- A thorough physical examination is critical to document the size, location, and appearance of bruises, along with checking for hepatosplenomegaly or lymphadenopathy.
- First-line laboratory tests include complete blood count (CBC) with platelet count, peripheral blood smear, prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level, as these tests can help identify common causes of bruising such as thrombocytopenia, coagulopathy, or bone marrow disorders 1.
Further Testing
If these initial tests are normal but clinical suspicion remains high, second-line tests may include von Willebrand factor antigen and activity, factor VIII and IX levels, platelet function tests, and bleeding time, to evaluate for less common bleeding disorders such as von Willebrand disease or hemophilia 1.
- Abnormal results should prompt referral to a hematologist for further evaluation and management, as the diagnosis and treatment of bleeding disorders often require specialized care.
- It is also important to consider the possibility of abuse in children with bruising, and to collaborate with a pediatric hematologist to ensure the most current evaluation and testing methods are used 1.
Key Considerations
- A systematic approach to the evaluation of easy bruising helps distinguish between common causes like medication effects or nutritional deficiencies from more serious conditions like hemophilia, von Willebrand disease, or leukemia.
- Close collaboration with a pediatric hematologist is necessary to ensure the most current evaluation and testing methods, especially in cases where the diagnosis is unclear or the patient has a complex medical history 1.
From the Research
Initial Workup for Easy Bruising
The initial workup for a patient presenting with easy bruising involves a comprehensive approach to identify underlying disorders.
- A detailed history is essential to provide sufficient information about the patient's condition, as noted in 2.
- A thorough physical examination and baseline laboratory studies can add more data to help the clinician decide if the patient is at significant risk of bleeding due to an underlying disorder 2.
- A family history of bleeding problems may suggest a hereditary coagulation defect, and medication review can identify pharmacologic causes of the bleeding or bruising 3.
Laboratory Evaluations
Initial laboratory evaluations should include:
- A complete blood count with platelet count 4, 5, 3
- Peripheral blood smear 4, 5, 3
- Prothrombin time (PT) 4, 5, 3
- Partial thromboplastin time (PTT) 4, 5, 3
- Fibrinogen 5
- International normalized ratio (INR) 5
Specialized Tests
More specialized tests, such as:
- Platelet Function Analyzer-100 4
- Mixing studies 4, 3
- Inhibitor assays 4
- Vitamin K challenge 3 may be helpful in diagnosing platelet function disorders, quantitative platelet disorders, factor deficiencies, and factor inhibitors.
Referral to a Specialist
Consultation with a hematologist is recommended when initial evaluation indicates a bleeding disorder or when suspicion remains high despite a normal laboratory workup result 5, 3.