What is the appropriate management for a patient presenting with bruising?

Management of Bruising in Primary Care

The appropriate management of a patient presenting with bruising should include a thorough assessment for underlying bleeding disorders, with initial laboratory testing including complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT) for patients with concerning features. 1

Initial Assessment

History Taking

• Age considerations: Age is a critical factor in evaluating bruising
  • Children under 6 months with any bruising require careful evaluation 2
  • Easy bruising in adults is common but requires systematic assessment
• Bruise characteristics:
  • Location (bruises in unusual locations like trunk, buttocks, ears are concerning)
  • Number of bruises
  • Pattern (patterned bruises may suggest non-accidental trauma) 2
• Bleeding history:
  • Previous excessive bleeding with procedures/surgeries
  • Spontaneous bleeding (nosebleeds, gum bleeding, heavy menstrual bleeding)
  • Family history of bleeding disorders 2
• Medication review:
  • Anticoagulants/antiplatelets
  • NSAIDs
  • Certain supplements (fish oil, ginkgo, etc.)

Physical Examination

• Comprehensive skin examination for additional bruises
• Mucosal examination for petechiae or bleeding
• Joint examination for evidence of hemarthrosis
• Assessment for hepatosplenomegaly or lymphadenopathy

Laboratory Evaluation

For patients with concerning features (multiple bruises, unusual locations, family history of bleeding, or excessive bleeding with procedures), initial laboratory testing should include:

1. Complete blood count (CBC) with platelet count
2. Peripheral blood smear
3. Prothrombin time (PT)
4. Partial thromboplastin time (PTT) 3

Interpretation of Results:

• Normal PT and PTT: Suggests platelet disorder (most commonly von Willebrand disease)
• Normal PT, prolonged PTT: Deficit in intrinsic pathway → perform mixing study
• Prolonged PT, normal PTT: Consider vitamin K deficiency → vitamin K challenge
• Prolonged PT and PTT: Consider liver failure workup 3

Management Algorithm

1. For isolated, explainable bruising with no concerning features:

   • Reassurance that local bruising does not adversely affect clinical outcomes 2
   • Apply pressure to bleeding sites for 5-10 seconds 2
   • Avoid trauma to the area

2. For frequent or excessive bruising:

   • Careful assessment of injection technique (if applicable)
   • Evaluation for coagulopathy or effects of anticoagulant/antiplatelet agents 2
   • Laboratory testing as outlined above

3. For confirmed bleeding disorders:

   • Referral to hematology for specialized testing and management
   • Preventive measures to avoid trauma
   • Patient education about the specific condition

Special Considerations

Pediatric Patients

• In children with bruising suspicious for abuse, a thorough evaluation for bleeding disorders is essential 2
• Skeletal survey may be indicated in young children with concerning bruising patterns 2
• Consider vitamin K deficiency in infants 2

Elderly Patients

• Age-related capillary fragility is common
• Medication review is particularly important
• Consider falls risk assessment

Common Pitfalls to Avoid

1. Missing child abuse: Bruising in pre-mobile infants should raise concern for non-accidental trauma 2

2. Attributing all bruising to medications: While anticoagulants increase bruising risk, significant bruising may indicate an underlying disorder

3. Inadequate laboratory evaluation: When suspicion for bleeding disorder is high despite normal initial testing, referral to hematology is warranted 1

4. Overlooking acquired causes: Liver disease, kidney disease, and certain medications can cause acquired bleeding disorders

5. Failing to reassure patients with normal findings: Most patients with easy bruising have no significant underlying disorder 4

By following this systematic approach, clinicians can effectively identify patients with potentially serious underlying disorders while appropriately reassuring those with benign causes of bruising.