What is the initial evaluation and management of bruising across the back in an adult patient?

Initial Evaluation and Management of Bruising Across the Back in an Adult Patient

In an adult patient with bruising across the back, immediately obtain a complete blood count with platelet count, PT/INR, aPTT, and fibrinogen level, while simultaneously conducting a focused history for medication use (anticoagulants, antiplatelets, NSAIDs, corticosteroids), trauma history, and bleeding symptoms to differentiate between medication-related, traumatic, or pathologic causes. 1, 2, 3

Critical Initial Assessment

History Elements That Matter

• Medication review is the highest yield initial step, as anticoagulants, antiplatelets, NSAIDs, and corticosteroids are extremely common causes of bruising in adults and directly affect management decisions 1
• Document any trauma history, including the mechanism and timing of injury, as direct blunt trauma to the back from falls or blows commonly causes deep muscle bruising 4
• Ask specifically about bleeding symptoms beyond bruising: gum bleeding, nosebleeds, heavy menstrual bleeding, prolonged bleeding after dental procedures, or bleeding after surgery, as these suggest an underlying bleeding disorder rather than isolated trauma 2, 3
• Obtain family history of bleeding disorders, particularly von Willebrand disease (prevalence 1 in 1000), as this is the most common inherited bleeding disorder that standard screening may miss 1, 2

Physical Examination Priorities

• Examine for mucocutaneous bleeding (petechiae, oral bleeding, conjunctival hemorrhage), which suggests platelet dysfunction, versus deep hematomas or joint bleeding, which indicate coagulopathy 2
• Document bruise size, color, and exact location with photography if possible, as bruise appearance changes rapidly 5
• In vulnerable populations (elderly, dependent adults), consider non-accidental trauma, though back bruising is less typical for abuse compared to other locations 3
• Assess for signs of liver disease (jaundice, spider angiomas, ascites) or renal disease (edema, uremic signs), as these commonly cause coagulopathy 1

Essential Laboratory Testing

First-Line Panel (Obtain Immediately)

• Complete blood count with platelet count and peripheral smear to identify thrombocytopenia, abnormal platelet morphology, or hematologic malignancies 1, 2, 3
• PT/INR to evaluate the extrinsic pathway and detect vitamin K deficiency, liver disease, warfarin effect, or factor VII deficiency 1, 2, 3
• aPTT to assess the intrinsic pathway and screen for hemophilia, heparin effect, and other factor deficiencies 1, 2, 3
• Fibrinogen level because fibrinogen disorders are missed by routine PT/aPTT testing 1

Critical Pitfall: Normal Coagulation Studies Do Not Exclude Bleeding Disorders

Normal PT and aPTT results do not rule out von Willebrand disease, Factor XIII deficiency, or platelet function disorders, which are common causes of abnormal bruising 1, 2, 3. If clinical suspicion remains high despite normal initial testing, proceed to:

• Von Willebrand factor panel (VWF antigen, VWF ristocetin cofactor activity, Factor VIII coagulant activity) 1, 2
• Liver function tests to assess hepatic synthetic function 1
• Renal function tests, as uremia affects platelet function 1

Interpreting Results and Next Steps

• Normal PT and prolonged aPTT: Perform a mixing study to differentiate factor deficiency from inhibitor 2, 3
• Prolonged PT and normal aPTT: Consider vitamin K deficiency or factor VII deficiency; a vitamin K challenge may be diagnostic 2
• Both PT and aPTT prolonged: Evaluate for liver failure, disseminated intravascular coagulation, or severe vitamin K deficiency 2, 3
• Normal PT, aPTT, and platelet count with persistent clinical concern: Refer to hematology for platelet function testing or Factor XIII assay 1, 2, 3

Immediate Management Based on Etiology

If Medication-Related (Most Common in Adults)

• Hold or adjust anticoagulation based on INR and bleeding severity 1
• Discontinue NSAIDs and antiplatelet agents if safe to do so 1
• Consider vitamin K administration if INR is elevated and patient is on warfarin 2

If Traumatic Without Coagulopathy

• Apply ice and compression to the affected area within the first 48 hours to reduce swelling 4
• Rest and restrict activity to prevent extension of the bruise 4
• Monitor for compartment syndrome if bruising is extensive or associated with severe pain, as deep muscle bruising can cause significant complications 4

If Coagulopathy Identified

• Consult hematology urgently if bleeding disorder is identified or strongly suspected despite normal initial testing 2, 3
• Avoid intramuscular injections and invasive procedures until coagulation status is clarified 6
• Consider imaging (CT or MRI) if there is concern for deeper injury, as bruising may indicate underlying organ damage 5

Special Populations

Elderly Patients

• Elderly patients frequently take multiple medications affecting coagulation, making medication review particularly critical 1
• Consider checking ferritin and inflammatory markers (ESR, CRP) if concerned about underlying malignancy or systemic disease 1
• Evaluate vitamin D and calcium/phosphate levels if metabolic bone disease may contribute to trauma susceptibility 1
• Bruise color cannot reliably predict age in older adults, as 16% of bruises were predominantly yellow within 24 hours in one study 7

Patients on Chemotherapy

This population requires different management (see pediatric guidelines), but similar principles apply: immediate platelet count assessment and holding anticoagulation 6