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

Initial Workup for Easy Bruising

The initial workup for a patient presenting with easy bruising should include a complete blood count (CBC), peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT) to screen for common bleeding disorders. 1, 2

History Assessment

When evaluating a patient with easy bruising, focus on:

• Bleeding history: Pattern, frequency, and severity of bruising
• Medication review: Anticoagulants, antiplatelets, NSAIDs, and other medications affecting hemostasis
• Family history: Hereditary bleeding disorders
• Timing of symptoms: Recent onset versus lifelong
• Associated symptoms: Mucocutaneous bleeding (suggesting platelet dysfunction) versus hemarthroses/hematomas (suggesting coagulopathy)

Consider using the International Society on Thrombosis and Hemostasis bleeding assessment tool to quantify bleeding severity and indicate possible pathology 1.

Physical Examination

Focus on:

• Distribution and characteristics of bruises
• Mucocutaneous bleeding sites (gums, nose)
• Joint examination for evidence of hemarthroses
• Petechiae or purpura (suggesting platelet disorders)
• Signs of underlying systemic disease

Laboratory Testing Algorithm

1. First-line tests:

   • Complete blood count (CBC) with platelet count
   • Peripheral blood smear
   • Prothrombin time (PT)/International Normalized Ratio (INR)
   • Activated partial thromboplastin time (aPTT)
   • Consider fibrinogen level

2. Interpretation and next steps:

   • Normal PT and aPTT: Suggests platelet disorder (most commonly von Willebrand disease) 1

     • Proceed with von Willebrand screen (von Willebrand factor antigen, ristocetin cofactor activity)
     • Consider platelet function studies

   • Normal PT, prolonged aPTT: Indicates deficit in the intrinsic pathway 2

     • Perform mixing study to differentiate factor deficiency from inhibitor
     • If mixing study normalizes, proceed with specific factor assays (VIII, IX, XI, XII)

   • Prolonged PT, normal aPTT: Suggests deficit in extrinsic pathway 2

     • Consider vitamin K challenge
     • Factor VII assay

   • Both PT and aPTT prolonged: Consider liver disease, DIC, or multiple factor deficiencies

     • Liver function tests
     • Fibrinogen and D-dimer levels

   • Abnormal platelet count: If low, evaluate for immune thrombocytopenia (ITP) or other causes of thrombocytopenia

Special Considerations

• In children with bruising, always consider non-accidental injury alongside bleeding disorders 3, 4
• Immune thrombocytopenia (ITP) is a transient, often self-resolving bleeding disorder that should be screened for at the time of presentation 3
• If initial testing is normal but clinical suspicion remains high, referral to a hematologist is warranted for additional specialized testing 1, 2

Common Pitfalls to Avoid

• Failing to consider medication-induced bleeding (including over-the-counter medications and supplements)
• Overlooking the possibility of non-accidental trauma, especially in vulnerable populations
• Assuming normal laboratory values rule out all bleeding disorders
• Not obtaining a thorough family history, particularly important in children who may not have experienced major bleeding episodes 1

If initial testing does not reveal an etiology in a patient with high suspicion for a bleeding disorder, refer to a hematologist for additional evaluation, as some rare platelet function disorders and mild forms of von Willebrand disease may not be detected by routine testing 1, 2.