What is the appropriate workup for a 65-year-old male presenting with spontaneous tender small bruises (ecchymoses) on the arm?

Workup of Spontaneous Tender Small Bruises in a 65-Year-Old Male

The appropriate workup for a 65-year-old male with spontaneous tender small bruises on the arm should begin with a complete blood count, coagulation studies (PT/PTT), and assessment for underlying bleeding disorders, with particular attention to medication history and vitamin deficiencies.

Initial Assessment

History Elements to Focus On

• Medication history (particularly anticoagulants, antiplatelets, NSAIDs)
• Recent trauma (even minor)
• Pattern and timing of bruise appearance
• Associated symptoms (bleeding from other sites, joint pain)
• Family history of bleeding disorders
• Dietary habits (potential vitamin deficiencies)
• Alcohol consumption
• Recent illnesses or infections

Physical Examination

• Document size, location, and appearance of bruises
• Check for bruising in other locations
• Examine for signs of systemic disease
• Assess for hepatosplenomegaly or lymphadenopathy

Laboratory Workup

First-Line Tests

• Complete blood count with platelet count
• Peripheral blood smear
• Prothrombin time (PT)
• Partial thromboplastin time (PTT)
• Liver function tests
• Renal function tests

Second-Line Tests (Based on Initial Results)

• Vitamin C level (if dietary deficiency suspected)
• Von Willebrand factor antigen and activity
• Factor assays (if coagulation studies abnormal)
• Platelet function studies (PFA-100)
• Fibrinogen level

Diagnostic Considerations

Age-Related Considerations

Spontaneous bruising in older adults has specific patterns that differ from abuse-related or pathological bruising:

• Nearly 90% of accidental bruises in older adults occur on the extremities 1
• Bruises on the face, lateral right arm, or posterior torso may warrant further investigation for potential elder mistreatment 2
• Bruise color cannot reliably predict bruise age 1

Common Causes in Older Adults

1. Medication effects

   • Anticoagulants (warfarin, DOACs)
   • Antiplatelets (aspirin, clopidogrel)
   • Certain antibiotics
   • Corticosteroids (skin thinning)

2. Age-related changes

   • Decreased skin elasticity and capillary fragility
   • Thinning of subcutaneous tissue

3. Medical conditions

   • Vitamin deficiencies (particularly vitamin C - scurvy can present with ecchymoses) 3
   • Liver disease (impaired clotting factor production)
   • Platelet disorders (quantitative or qualitative)
   • Von Willebrand disease (most common inherited bleeding disorder) 4
   • Vascular disorders

Management Approach

The management should be directed at the underlying cause:

1. If medication-related:

   • Consider dose adjustment or alternative medications
   • Monitor more frequently

2. If nutritional deficiency:

   • Appropriate supplementation (e.g., vitamin C for scurvy)
   • Dietary counseling

3. If coagulopathy identified:

   • Referral to hematology for specialized management
   • Factor replacement or other specific therapies

4. If vascular issue:

   • Consider vascular surgery consultation for conditions like venous thrombosis 5

Special Considerations

When to Suspect More Serious Pathology

• Multiple bruises in unusual locations
• Accompanying systemic symptoms (fever, weight loss)
• Abnormal bleeding from other sites
• Rapidly progressive symptoms
• Family history of bleeding disorders

Pitfalls to Avoid

1. Don't assume all bruising in elderly is benign - while common, spontaneous bruising can be the first sign of serious underlying conditions
2. Don't overlook medication effects - many older adults are on multiple medications that can affect coagulation
3. Don't judge bruise age by color - contrary to common belief, yellow coloration can appear within the first 24 hours 1
4. Don't miss vitamin deficiencies - nutritional deficiencies like scurvy can present with ecchymoses and are easily treatable 3

In elderly patients with bruising, a systematic approach focusing on medication history, physical examination patterns, and targeted laboratory testing will help identify the underlying cause and guide appropriate management.