What is the initial workup for a patient presenting with bruising?

From the Guidelines

The initial workup for a patient presenting with bruising should begin with a thorough history and physical examination, focusing on the onset and pattern of bruising, associated symptoms, medication use, family history of bleeding disorders, and recent trauma. The history should include questions about the patient's medical history, including any previous bleeding disorders or coagulopathies, as well as any medications that may increase the risk of bleeding, such as anticoagulants like warfarin, DOACs, aspirin, or NSAIDs 1. Physical examination should document the size, location, and appearance of bruises, along with assessment for other signs of bleeding such as petechiae or mucosal bleeding.

Key components of the initial workup include:

• Laboratory testing with a complete blood count (CBC) with platelet count, peripheral blood smear, prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level
• Assessment for von Willebrand disease (VWD) and other coagulation disorders, as these can be detected by PT and aPTT, but may require specific testing such as von Willebrand factor antigen and activity assays 1
• Consideration of platelet function disorders, which can be screened for using a PFA-100, but may require additional testing such as platelet aggregation studies 1

A systematic approach to the initial workup, including a thorough history, physical examination, and laboratory testing, is essential to distinguish between common causes of bruising and more serious underlying conditions. For patients with concerning findings, such as spontaneous bruising, extensive bruising disproportionate to reported trauma, or abnormal initial lab results, referral to a hematologist may be warranted to further evaluate and manage any underlying coagulopathies or platelet disorders 1.

From the Research

Initial Workup for Bruising

The initial workup for a patient presenting with bruising involves a comprehensive history, physical examination, and laboratory testing.

• A patient history can help determine whether the bruising is abnormal, and a family history of bleeding problems may suggest a hereditary coagulation defect 2, 3.
• Medication review can identify pharmacologic causes of the bleeding or bruising 2, 4.
• Physical examination findings such as mucocutaneous bleeding suggest that the underlying condition is caused by platelet dysfunction, whereas hemarthroses or hematomas are more common in coagulopathy 2.

Laboratory Testing

Initial laboratory testing includes:

• A complete blood count (CBC) 2, 3
• Peripheral blood smear 2, 3
• Prothrombin time (PT) 2, 4, 3
• Partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT) 2, 4, 3
• Fibrinogen 3
• A normal PT and PTT indicate a platelet disorder, the most common of which is von Willebrand disease 2.
• A normal PT and prolonged PTT signal a deficit in the intrinsic pathway, and a mixing study should be performed 2.

Special Considerations

• Nonaccidental trauma should be considered, especially in vulnerable populations such as children 5, 6.
• Consultation with a hematologist is recommended when initial evaluation indicates a bleeding disorder or when suspicion remains high despite a normal laboratory workup result 2, 3.