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Evaluation of a patient with bruising

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

It is important to obtain a detailed personal and family history together with a physical examination in order to differentiate "normal" from "abnormal" bruising (1,2).

past medical history (which should include comorbid conditions currently present)
- childhood illness - chemotherapy or radiation therapy for childhood malignancies may later lead to treatment related bleeding from bone marrow disorders (e.g. - myelodysplasia or leukaemia)
- autoimmune disorders which may affect the blood vessels
- renal disease - causing platelet dysfunction
- hepatic disorders - may affect the numbers of platelets, platelet function, quantity of coagulation proteins or the quality of the skin and connective tissue (2)
- thyroid dysfunction - skin and subcutaneous tissue may be affected
- pain or swelling in a joint or reluctance to move a limb may be due to haemarthroses (1)
nutrition of the patient
- children on a limited diet is at a risk of developing nutritional deficiencies which in turn may cause coagulopathy, vascular fragility and/or bruising
- in teenage girls and in middle aged persons certain eating behaviours (e.g. - avoiding meat or fat due to an eating disorder or avoiding fruits and vegetables as a part of specific diet) may lead to nutritional deficiencies
- elderly people - especially those living alone or in a nursing home and in elders with poorly fitting dentures, lack of access to certain foods or a decreased appetite may also face nutritional deficiencies (2)
symptoms which suggest an underlying platelet or coagulation disorder
- epistaxis
- gingival or mucocutaneous bleeding (1)
- excessive bleeding from childhood cuts or abrasions
- menorrhagia
- postpartum haemorrhage
- haematuria (2)
- excessive bleeding after tooth extractions or minor surgery (for example, tonsillectomy) (3)
history of medication used including over-the-counter medications and herbal supplements which may cause bleeding abnormalities (2)
family history of
- any known bleeding disorder in the family such as haemophilia, von Willebrand disease or platelet function defects
  - new genetic mutation may be responsible for 30% of haemophilia cases hence there will be no family history in these patients (1)
- female family members with menorrhagia or members of both sexes with bleeding may indicate a non sex-linked disease e.g. - von Willebrand disease or factor XI deficiency
- bleeding in males and with skipped generations may indicate sex-linked disorders such as haemophilia A and B (although rarely it may be seen in females in case of consanguinity and rare acquired antibody disorders)
- a history of consanguinity - suspect rare conditions such as autosomal recessively inherited (factor V, factor X and factor XIII) deficiencies
- a history of Ehlers-Danlos syndrome (2)
if the patient is an infant or child, inquire specifically about
- whether the child is crawling since bruising is rare in infants before they crawl
- any history at birth of conditions suggestive of an undiagnosed bleeding disorder
  - any bruising or bleeding at birth or from the umbilical stump
  - haematoma after routine intramuscular vitamin K given at birth
  - bleeding from the heel prick after the Guthrie test (1)

During the physical examination,

in children record the distribution, number, site, and size of bruising together with any petechiae, ecchymoses, and subcutaneous haematoma
- pictorial or photographic records (with parent consent) should be used
- also look for any additional signs such as abrasion of the skin or the outline of a hand or a belt (1)
examine the pattern of bruising
- in dependent areas - can be due to thrombocytopaenia or stasis factor
- only on the arms or legs - suggests trauma or changes in the skin or subcutaneous tissue
- around the eyes - connective tissue disorder (2)
- in atypical areas such as back, buttocks, arms, and abdomen - suspect bleeding disorder, or non-accidental injury (1)
- typically over extensor surfaces of forearms - suspect senile purpura (4)
examine the skin for
- pallor - suggests anaemia
- purpura or petechiae - thrombocytopenia (2)
- thinning and dry skin - can be due to aging, thyroid disease, inherited disorders
- brittle hair and nails - due to nutritional factors, aging and thyroid diseases
- evidence of delayed healing (multiple scars or unresolved wounds) - may suggest steroids, thyroid disease, aging or factor XIII deficiency
examine the joints:
- for any underlying rheumatological disorder (2)
- hypermobility - suggestive of Ehlers-Danlos syndrome (1)
examine for hepatosplenomagaly (may be due to systemic disease) or for features of chronic liver disease (ascites, caput medusa or spider telangiectasias) (2)
lymphadenopathy may suggest a viral illness or a lymphoid malignancy (2)

Note:

in clinical practice assessment of the age of a bruise according to the different colours (red, blue, yellow, green) is inaccurate
- although some consider red/blue/purple is seen in recent bruising and yellow/brown and green with older resolving bruises, any of these colours can be present at any time before the bruise heals. Hence an accurate estimate of the age of a bruise cannot be done by clinical assessment of the bruise (5)

Reference:

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