What is the initial workup for a patient presenting with spontaneous ecchymoses (bruises) that are tender to the touch, with otherwise normal physical examination findings?

From the Guidelines

For a patient with spontaneous ecchymosis that are tender to touch but otherwise normal physical exam, the initial workup should include a complete blood count (CBC) with platelet count, coagulation studies (PT/INR, PTT), and a comprehensive metabolic panel. I would also recommend obtaining a detailed medication history, focusing on anticoagulants, antiplatelets, NSAIDs, and supplements 1. Additional first-line tests should include liver function tests, as liver disease can impair clotting factor production, and a urinalysis to check for hematuria.

Initial Evaluation

The physical examination should be expanded to carefully document the distribution, size, and characteristics of the ecchymoses, and to look for other signs of bleeding such as petechiae or purpura. This approach helps identify whether the spontaneous bruising is due to a platelet disorder, coagulation factor deficiency, vascular fragility, or medication effect, which will guide further management.

Specialized Testing

If the patient has a family history of bleeding disorders or the initial workup is inconclusive, specialized tests like von Willebrand factor assay, factor XIII levels, and platelet function studies may be warranted 1. However, it's essential to note that some bleeding disorders, such as von Willebrand disease, may not be reliably detected by standard screening tests like PT and aPTT.

Management

Patients should be advised to avoid NSAIDs and other medications that may worsen bleeding tendency until a diagnosis is established. A thorough evaluation, including a detailed history and physical examination, is crucial in determining the underlying cause of spontaneous ecchymosis and guiding appropriate management. In some cases, consultation with a pediatric hematologist may be necessary to interpret test results and determine the need for further testing 1.

From the Research

Initial Workup for Spontaneous Ecchymosis

The initial workup for a patient with spontaneous ecchymosis, which are tender to the touch and have a normal physical examination otherwise, involves a combination of laboratory tests and physical examination findings.

• The patient's history, including a family history of bleeding problems, can help determine whether the bruising or bleeding is abnormal 2.
• A medication review can identify pharmacologic causes of the bleeding or bruising 2.
• Physical examination findings, such as mucocutaneous bleeding, suggest that the underlying condition is caused by platelet dysfunction, whereas hemarthroses or hematomas are more common in coagulopathy 2.
• Initial laboratory testing includes:
  • Complete blood count (CBC)
  • Peripheral blood smear
  • Prothrombin time (PT)
  • Partial thromboplastin time (PTT) 2
• A normal PT and PTT indicate a platelet disorder, the most common of which is von Willebrand disease 2.
• A normal PT and prolonged PTT signal a deficit in the intrinsic pathway, and a mixing study should be performed 2.
• Routine screening tests, such as a complete blood cell count, platelet count, and evaluation of a peripheral blood sample, a prothrombin time, and an activated partial thromboplastin time, can help identify coagulation disorders 3.
• Coagulation panels, including PT, PTT, and INR, can evaluate the coagulation pathway and monitor warfarin and heparin therapy, evaluate for vitamin K deficiency, and assess hemostatic function in the setting of bleeding 4.

Laboratory Tests

Laboratory tests, such as thromboelastography and rotational thromboelastometry, offer more reliable measures of coagulation function 4.

• The sensitivity of coagulation screening tests to clinically significant abnormalities is low, and the use of these tests should be considered in systemically ill patients, those with a prior history of bleeding or family history of bleeding, patients on anticoagulation, or patients with active hemorrhage and signs of bleeding 5, 4.
• The International Society on Thrombosis and Hemostasis has developed a bleeding assessment tool that can be used to indicate possible pathology 2.

Diagnosis

Diagnosis of the underlying cause of spontaneous ecchymosis requires a comprehensive approach, including patient history, physical examination, and laboratory tests 6, 3, 5, 2, 4.