Practice Rational Testing

Investigating easy bruising in an adult

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j251 (Published 09 February 2017) Cite this as: BMJ 2017;356:j251
  1. Laura B Harrison, medical student1,
  2. Michael J Nash, consultant haematologist2,
  3. David Fitzmaurice, professor or primary care3,
  4. Jecko Thachil , consultant haematologist2
  1. 1University of Manchester, Manchester, UK
  2. 2Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
  3. 3Primary Care Clinical Sciences, Institute of Applied Health Research College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
  1. Correspondence to J Thachil jecko.thachil{at}cmft.nhs.uk
  • Accepted 25 December 2016

What you need to know

  • In those without a personal or family history, easy bruising is unlikely to be a bleeding disorder.

  • History and clinical examination and widely available laboratory tests are often sufficient to reach a diagnosis, or to reassure.

  • Consider nutritional deficiencies, age related bruising, purpura simplex, drugs, and physical abuse in patients with a first episode of bruising.

A 78 year old woman presents with a three month history of easy bruising. She also feels tired and has lost her appetite. She has hypertension and a history of myocardial infarction, and has been taking amlodipine and aspirin for the last five years. Clinical examination reveals bruising to the arms, legs, and abdomen, and poor oral health.

How should I assess the patient?

History

Discuss the bruises. Ask questions such as:

  • What exactly does the patient mean by a bruise?

  • Do they have any bruises now or photographs of bruises previously?

  • Have they noticed small red spots (petechiae) or purple patches (purpura) with the bruises?

  • Is bruising spontaneous or inflicted by trauma? Is the severity out of proportion to the trauma?

Bruising limited to the limbs suggests trauma, and that on the trunk and other areas is more suggestive of an underlying bleeding disorder.1 Bruises are considered to represent a bleeding disorder when five or more (greater than 1 cm in size) occur simultaneously in exposed areas. Petechiae, and haematomas, when occurring without trauma, are suggestive of a bleeding disorder2(Box 1).

Box 1: Causes of easy bruising in adults

Common
  • Senile purpura (fig 1)

  • Medications (antiplatelet agents, anticoagulants, and non-steroidal anti-inflammatories)

  • Excess alcohol use and liver cirrhosis

  • von Willebrand disease (prevalence 1%-2% of general population)

  • Purpura simplex or easy bruising syndrome

  • Vitamin C and vitamin K deficiencies

  • Vasculitis

  • Gastrointestinal diseases

Rare
  • Haemophilia and rare coagulation factor (I, II, V, VII, XI) deficiencies

  • Acquired haemophilia or von Willebrand disease (older individuals …

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