What is the next step for a patient presenting with easy bruising?

Evaluation of Easy Bruising

Begin with a targeted bleeding history and medication review, followed by initial laboratory screening with CBC with platelet count, peripheral blood smear, PT, and aPTT. 1

Initial Clinical Assessment

Critical History Elements

• Ask specifically about significant bleeding symptoms including bleeding after surgery or dental procedures, epistaxis requiring intervention, joint hemorrhages (hemarthroses), and menorrhagia in females to determine if laboratory testing is warranted 1, 2

• Document all medications that increase bleeding risk including anticoagulants, antiplatelet agents, NSAIDs, corticosteroids, and alternative therapies, as these affect both bleeding tendency and coagulation test results 1, 2

• Obtain family history of specific bleeding disorders or ethnicity associated with higher rates of certain bleeding disorders 1

• Assess trauma history to determine if the bruising pattern is explained by reported trauma, and evaluate age/developmental capabilities (particularly in children) to determine if bruising location is consistent with normal activity 1

Physical Examination Red Flags

• Evaluate bruising location and pattern - bruising on buttocks, ears, genitals, or patterned bruising has higher specificity for abuse in children and warrants different evaluation 1

• Look for signs of systemic illness including Ehlers-Danlos syndrome, scurvy, cancer, infiltrative disorders, or arteriovenous malformations 1

• Identify atypical features such as fever, bone or joint pain, skeletal or soft-tissue morphologic abnormalities, non-petechial rash, lymphadenopathy, or hepatosplenomegaly - these are not typical of isolated bleeding disorders and should prompt additional testing including bone marrow evaluation 3

Initial Laboratory Screening Panel

Order the following tests for all patients with easy bruising and clinical concern: 1, 2

• Complete blood count (CBC) with platelet count
• Peripheral blood smear
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)
• Add fibrinogen level if PT or aPTT are abnormal to detect fibrinogen defects 1

Critical Limitations of Screening Tests

• PT and aPTT do NOT reliably detect von Willebrand disease or Factor XIII deficiency - these require specific testing if clinical suspicion remains despite normal screening tests 1, 2

• Normal platelet count does not exclude platelet function disorders 2

Algorithm Based on Initial Results

If Screening Tests Are Normal

• Avoid extensive testing without clinical indication as the extreme rarity of some bleeding disorders makes universal screening unreasonable 1

• Consider referral to hematology if high clinical suspicion remains despite normal laboratory workup, or if specialized testing (such as platelet function testing or von Willebrand disease workup) is needed 1

If Screening Tests Are Abnormal

• Refer to hematology when initial laboratory evaluation indicates a bleeding disorder or complex cases require expert interpretation 1

• For patients on anticoagulants (warfarin, DOACs), evaluate for liver disease and warfarin effect 4

Special Considerations

Pediatric Patients

• Bone marrow examination is NOT necessary in children and adolescents with typical features of ITP (isolated thrombocytopenia with otherwise normal CBC and peripheral smear, no systemic symptoms) 3

• Testing for antinuclear antibodies is not necessary in the evaluation of children and adolescents with suspected ITP 3

When to Consider Bone Marrow Evaluation

Perform bone marrow examination if: 3

• Abnormal hemoglobin level, white blood cell count, or white cell morphology
• Fever or bone/joint pain present
• Family history of low platelets or easy bruising
• Skeletal or soft-tissue morphologic abnormalities
• Non-petechial rash
• Lymphadenopathy or hepatosplenomegaly

Common Pitfalls to Avoid

• Do not overlook medication effects - certain drugs affect both bleeding tendency and test interpretation, particularly platelet function testing 1

• Do not assume normal platelet count excludes all platelet disorders - platelet function defects require specialized testing 2

• Do not rely solely on PT/aPTT to exclude bleeding disorders - von Willebrand disease is the most common inherited bleeding disorder and is not reliably detected by these screening tests 1, 2