Evaluation of Easy Bruising

Initial Clinical Assessment

The American College of Physicians recommends beginning with a targeted bleeding history and medication review, followed by initial laboratory screening with CBC with platelet count, peripheral blood smear, PT, and aPTT to evaluate easy bruising in patients 1
A thorough history should include asking specifically about significant bleeding symptoms, such as bleeding after surgery or dental procedures, epistaxis requiring intervention, joint hemorrhages, and menorrhagia in females, to determine if laboratory testing is warranted 1, 2
Documenting all medications that increase bleeding risk, including anticoagulants, antiplatelet agents, NSAIDs, corticosteroids, and alternative therapies, is crucial as these affect both bleeding tendency and coagulation test results 1, 2
Obtaining a family history of specific bleeding disorders or ethnicity associated with higher rates of certain bleeding disorders is essential 1
Assessing trauma history to determine if the bruising pattern is explained by reported trauma, and evaluating age/developmental capabilities, particularly in children, is necessary 1

The initial laboratory screening panel should include a complete blood count (CBC) with platelet count, peripheral blood smear, prothrombin time (PT), and activated partial thromboplastin time (aPTT) for all patients with easy bruising and clinical concern 1, 2
Adding fibrinogen level if PT or aPTT are abnormal is recommended to detect fibrinogen defects 1

In pediatric patients, bone marrow examination is not necessary in children and adolescents with typical features of ITP, and testing for antinuclear antibodies is not necessary in the evaluation of children and adolescents with suspected ITP 3
Bone marrow examination should be considered if abnormal hemoglobin level, white blood cell count, or white cell morphology, fever or bone/joint pain, family history of low platelets or easy bruising, skeletal or soft-tissue morphologic abnormalities, non-petechial rash, lymphadenopathy, or hepatosplenomegaly are present 1, 3

Medication effects should not be overlooked, as certain drugs affect both bleeding tendency and test interpretation, particularly platelet function testing 1
A normal platelet count should not exclude all platelet disorders, as platelet function defects require specialized testing 2
PT/aPTT should not be relied upon solely to exclude bleeding disorders, as von Willebrand disease is not reliably detected by these screening tests 1, 2