Workup for Easy Bruising in a 65-Year-Old Female
Begin with a focused history and initial laboratory screening including CBC with platelet count, PT, aPTT, and peripheral blood smear, recognizing that normal PT/aPTT does not exclude von Willebrand disease or platelet function disorders. 1, 2
Essential History Components
Obtain specific information about bleeding symptoms that suggest an underlying disorder: 2
- Significant bleeding after surgery or dental procedures (indicates possible coagulation defect) 3, 2
- Epistaxis frequency and severity (mucocutaneous bleeding suggests platelet dysfunction) 3, 4
- Family history of bleeding disorders (suggests hereditary coagulopathy) 2, 4
- Complete medication review including anticoagulants, antiplatelets, NSAIDs, steroids, and herbal supplements (common pharmacologic causes) 1, 2
Document the bruising pattern specifically: 2
- Location (spontaneous vs. trauma-related areas) 4
- Size and frequency 5
- Temporal relationship to any trauma 2
Physical Examination Focus
Look for specific findings that indicate systemic disease: 2
- Mucocutaneous bleeding (petechiae, gingival bleeding) suggests platelet dysfunction or thrombocytopenia 4
- Joint swelling or hemarthroses indicate coagulopathy rather than platelet disorder 4
- Signs of connective tissue disorders such as hyperelastic skin or joint hypermobility (Ehlers-Danlos syndrome) 1, 6
- Hepatosplenomegaly or lymphadenopathy (suggests malignancy or infiltrative disorder) 1
Initial Laboratory Testing
Order the following screening panel: 2, 7
- Complete blood count with platelet count (detects thrombocytopenia or reactive thrombocytosis) 1, 2
- Peripheral blood smear (evaluates platelet morphology and identifies hematologic malignancies) 2, 7
- Prothrombin time (PT) (screens extrinsic pathway and liver function) 2, 7
- Activated partial thromboplastin time (aPTT) (screens intrinsic pathway) 2, 7
- Fibrinogen level if PT or aPTT are abnormal (detects fibrinogen defects) 1, 2
Critical Pitfall to Avoid
Normal PT and aPTT do NOT exclude bleeding disorders - these tests miss von Willebrand disease (the most common inherited bleeding disorder affecting 1 in 1000 people), Factor XIII deficiency, and platelet function disorders. 1, 2
Interpretation Algorithm
If PT and aPTT are Normal:
- Consider von Willebrand disease (most likely diagnosis in this scenario) 1, 4
- Consider platelet function disorder requiring specialized testing 1, 2
- Refer to hematology for von Willebrand factor testing and platelet aggregation studies 2, 4
If PT Normal, aPTT Prolonged:
- Perform mixing study to distinguish factor deficiency from inhibitor 4, 7
- Consider acquired Factor VIII inhibitor (can present with severe spontaneous bruising in elderly patients) 8
- Evaluate intrinsic pathway factors (VIII, IX, XI, XII) 7
If PT Prolonged, aPTT Normal:
- Consider vitamin K deficiency (trial of vitamin K supplementation) 4, 7
- Evaluate Factor VII deficiency 7
- Assess for early liver disease 1
If Both PT and aPTT Prolonged:
- Evaluate for liver disease/cirrhosis (decreased clotting factor production) 1, 7
- Consider disseminated intravascular coagulation (DIC) 1, 2
- Assess for vitamin K deficiency 1
Age-Specific Considerations
In a 65-year-old female, prioritize: 1
- Senile purpura from vascular and skin thinning (clinical diagnosis, no testing needed) 1
- Medication-induced bruising (extremely common in this age group) 1
- Acquired bleeding disorders including acquired Factor VIII inhibitor 8
- Occult malignancy causing thrombocytopenia or coagulopathy 1