What is the appropriate workup for an adult patient with no known medical history presenting with bruising all over the body?

Workup for Adult with Widespread Bruising

For an adult presenting with bruising all over the body, immediately obtain a complete blood count with platelet count, peripheral blood smear, PT, aPTT, and fibrinogen level (if PT or aPTT abnormal), while simultaneously conducting a focused history for bleeding symptoms, medications, and trauma history. 1, 2, 3

Initial Laboratory Testing

The screening panel must include: 1, 2, 3

• Complete blood count (CBC) with platelet count to detect thrombocytopenia or hematologic malignancy 1, 3
• Peripheral blood smear to identify abnormal cell morphology 1, 2
• Prothrombin time (PT) to assess extrinsic pathway 1, 2, 3
• Activated partial thromboplastin time (aPTT) to assess intrinsic pathway 1, 2, 3
• Fibrinogen level if PT or aPTT are abnormal 1, 3

Critical pitfall: Normal PT and aPTT do NOT exclude bleeding disorders—von Willebrand disease and Factor XIII deficiency are not reliably detected by these screening tests and require specific testing if clinical suspicion remains high. 1, 4

Focused History Components

Document the following specific elements: 1, 2, 3

Bleeding symptoms: 1, 2

• Significant bleeding after surgery or dental procedures
• Epistaxis requiring medical intervention
• Joint hemorrhages (hemarthroses)
• Menorrhagia in women

Medication review: 1, 4, 2

• NSAIDs, anticoagulants, antiplatelet agents
• Corticosteroids
• Alternative therapies and supplements (these affect both bleeding tendency and coagulation test results)

Family history: 1, 2

• Specific bleeding disorders
• Ethnicity associated with higher rates of certain bleeding disorders

Trauma history: 1

• Determine if bruising pattern is explained by reported trauma
• Assess for implausible explanations

Physical Examination Priorities

Evaluate for: 1, 2, 3

• Location and pattern of bruising (patterned bruising suggests inflicted injury) 1, 4
• Signs of systemic illness: Ehlers-Danlos syndrome, scurvy, malignancy, infiltrative disorders 1, 4
• Mucocutaneous bleeding (suggests platelet dysfunction) 2
• Hemarthroses or hematomas (more common in coagulopathy) 2

Interpretation Algorithm Based on Initial Results

If PT and aPTT both normal: 2, 3

• Most likely platelet disorder (von Willebrand disease is most common)
• Consider platelet function testing (PFA-100), though consultation with hematologist recommended for interpretation 1

If PT normal and aPTT prolonged: 2, 3

• Indicates intrinsic pathway deficit
• Perform mixing study to differentiate factor deficiency from inhibitor 2, 3

If PT prolonged and aPTT normal: 2, 3

• May indicate extrinsic pathway disorder
• Consider vitamin K deficiency 1, 2

If both PT and aPTT prolonged: 2, 3

• Workup for liver failure 2
• Consider disseminated intravascular coagulation (DIC), evaluating for primary causes including trauma, sepsis, and primary bleeding disorders 1

Mandatory Hematology Referral Indications

Refer when: 1, 4

• Initial laboratory evaluation indicates a bleeding disorder
• High clinical suspicion remains despite normal laboratory workup
• Specialized testing is needed (von Willebrand disease, Factor XIII deficiency)
• Complex cases require expert interpretation

Special Considerations

Avoid extensive testing without clinical indication—the extreme rarity of some bleeding disorders makes universal screening unreasonable. 1, 4 However, if history suggests significant bleeding symptoms or family history is positive, pursue comprehensive evaluation even with normal screening tests. 2, 5, 6

Document bruising photographically if there is any concern for non-accidental trauma, as bruise appearance changes rapidly. 7