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Bruising – Excluding NAI

Bruising in the elderly is a common presentation. This chart on A4Medicine can be helpful in data gathering and plan further investigations based on clinical suspicion. The clinician should consider Vitamin C deficiency as an easily treatable cause of bruising.Perio-orbital bruising can be a presentation of  Nueroblastoma in children and should alert the clinician to examine the child further. A list of possible first line investigations is also available. Senile purpura is a common cause of bruising in the elderly.

Common problem Bruise – haematoma which forms due to bleeding under intact skin in s/c tissue due to vascular damage or injury Damage that causes bleeding can be
○ trauma external to vessel
○ internal to the vessel
○ vessel itself Colour changes
Red discoloration → purple → brownish yellow Usually disappears within 2-3 weeks A detailed history often provides sufficient information Bruising is reported ↑ frequently by women than men

History-What does the patient mean Circumstances -spontaneous or following trauma ? dental procedures Age of manifestation General overall health
○ past medical history
○ past surgical history- all operations , dental extractions etc Type of bleeding ie epistaxis , menorrhagia or hematomas Any petechiae or purple patches ( purpura ) with bruises Nutritional status Alcohol use or risk factors for chronic liver disease Prescribed and OTC drug history Family history – particularly
○ bleeding disorders –> haemophilia ( rare 1 in 5000 ) , von Willerbrand’s disease or a platelet disorder
○ tendency to bruise or bleed easily or spontaneously
○ menorrhagia or post-partum bleeding – may indicated non sex linked dis as von Willerbrands or factor XI deficiency
○ consanguinity ↑ risk autosomal recessively inherited disorders as factor X deficiency
○ Hereditaey haemorrhagic telangiectasia , Ehler-Danlos syndrome or osteogenesis imperfecta Colour of bruising
 not a reliable indicator of age

Examination-Location and pattern of bruising
○ distribution , number , site , shape 
○ presence of petechiae and ecchymoses
○ dependent areas – thrombocytopenia or stasis factors
○ atypical areas eg on trunk ( consider bleeding disorder or NAI _
○ patterned bruising eg hand print or belt
○ distribution for eg- only on arms and legs ( trauma or changes in skin and s/c tissue )
○ location – dorsum of hands , extensor surface of the forearms and the shins → senile purpura Signs of malnutrition ( brittle hairs , nails , cachexia ) Joints ( haemarthroses ) Abdomen ( signs of chronic liver disease ) Oral cavity ( gum hyperplasia , periodantal inflammation -Vit C deficiency ) Lymphadenopathy

Causes- Trauma Consider accidental and non-accidental injuries Cupping or coining may contribute towards it   Vascular- Senile purpura ( common ) Senile purpura ( easy bruising syndrome ) young ♀ Hereditary haemorrhagic telangiectasia ( HHT – rare ) Ehler-Danlos syndrome Osteogenesis imperfecta Vitamin C deficiency ( Scurvy )   Platelet disorders -Acute idiopathic thrombocytopenic purpura ( ITP ) Chronic ITP Henoch-Schlonlein purpura ( HSP ) Aplastic anaemia Malignancy End stage CKD Liver disease    Coagulation -May be inherited or acquired
Negative family hx → does not r/o genetically inherited disorder
 Haemophilia A ( Factor VIII deficiency ) and Haemophilia B 
( factor IX deficiecny ) Liver disease Vitamin K deficiency Von Willerbrand’s disease- most common inherited coagulation disorder prevalence 1-2 % gen population Amyloidosis  Drugs-Corticosteroids Platelet inhibitors
○ aspirin
○ clopidogrel
○ SSRI’s Drugs causing thrombocytopenia
○ alcohol
○ antibiotics – cephalosporins , nitrofurantoin , penicillins ,sulfonamides
○ quinine
○ propranolol
○ thiazide diuretics Anticoagulants
○ Warfarin
○ Heparins

Investigations-Full blood count
○ low Hb may suggest that bruising is long standing or associated with bleeding elsewhere for eg GI tract
○ isolated low platelet count suggests thrombocytopenia as the likely cause
○ abnormal total and differential WCC + low platelets –> bone marrow disorder Blood film
○ identify morphological abnormalities in blood cells
○ platelet – shape and colour (can suggest inherited platelet disorder ) Clotting screen
○ PT , APTT and fibrinogen
○ can suggest inherited or acquired coagulation disorder INR in people taking warfarin Kidney and liver function tests TSH Urine dipstick test
○ non visible haematuria may suggest and underlying bleeding disorder or vasculitis Special tests -Von Willerbrand’s disease- VWF :Ag , VWF : Rco , FVIII Platelet function tests Coagulation factor assay Mixing studies Inhibitor assays Urea clot stability or euglobulin clot lysis time Alpha 2-Antiplasmin level and PAI-1 activity Reptilase time

Referral-Admit if significant active bleeding Refer children and young people for leukaemia if they have
○ unexplained petechiae or
○ hepatosplenomegaly or
○ FBC suggests leukaemia
 Children suspected Neuroblastoma –> refer for appt within 48 hrs
○ periorbital bruising
○ palpable mass or
○ unexplained enlarged abdominal organ
 Refer all other adults if there is
○ a low platelet count
○ abnormal clotting screen
○ normal blood results but a bleeding disorder is still suspected
○ positive family history ( especially ♀ with menorrhagia )

PT measures factors of the extrinsic 
& common pathways – eg factor VII 
deficiency and Vit K deficiency will ↑ PT
 PTT measures intrinsic & common
 pathways eg factor VIII and 
IX deficiency will ↑ PTT


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