Evaluation of a patient with bruising

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:

• 1. Anderson JA, Thomas AE. Investigating easy bruising in a child. BMJ. 2010;341:c4565.
• 2. Valente MJ, Abramson N.Easy bruisability. South Med J. 2006;99(4):366-70.
• 3. Vora A, Makris M. Personal practice: An approach to investigation of easy bruising. Arch Dis Child. 2001;84(6):488-91.
• 4. Ballas M, Kraut EH. Bleeding and bruising: a diagnostic work-up. Am Fam Physician. 2008;77(8):1117-24.
• 5. Maguire S et al. Can you age bruises accurately in children? A systematic review. Arch Dis Child. 2005;90(2):187-9.