Bruising : Triage Questionnaire

Spontaneous bruising in adults can arise from a variety of underlying conditions, necessitating a comprehensive approach to diagnosis and management. Initial evaluation should focus on identifying potential hematologic disorders, medication effects, and underlying systemic diseases.

One of the primary considerations in adults presenting with spontaneous bruising is the possibility of hematologic disorders such as thrombocytopenia or coagulopathy. For instance, idiopathic thrombocytopenic purpura (ITP) is characterized by persistently low platelet counts, which significantly increases the risk of spontaneous bruising and other bleeding manifestations (Enger et al., 2010). Similarly, von Willebrand disease (VWD) is another hematological condition that can lead to easy bruising, particularly in cases where there is a deficiency in von Willebrand factor (Echahdi et al., 2017). The clinical presentation of VWD often includes mucocutaneous bleeding, such as easy bruising and epistaxis, which can vary in severity depending on the residual activity of the von Willebrand factor (Rashid et al., 2020).

In addition to hematologic causes, medication use can also contribute to spontaneous bruising. The concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) and certain antidepressants, such as citalopram, has been associated with increased bruising incidents due to their effects on platelet function and coagulation pathways (Desilets et al., 2012). It is crucial for clinicians to obtain a thorough medication history, including over-the-counter medications, to identify potential drug interactions that may exacerbate bleeding tendencies.

Furthermore, specific syndromes such as Ehlers-Danlos syndrome (EDS), particularly the vascular type, can predispose individuals to spontaneous bruising due to the fragility of blood vessels and connective tissue abnormalities (Advenier et al., 2013; Kazakov et al., 2021). Patients with EDS often present with thin, easily bruised skin and may experience spontaneous arterial ruptures, which can have serious implications for management (Kazakov et al., 2021). Similarly, conditions like Gardner-Diamond syndrome, characterized by recurrent spontaneous bruising without an identifiable cause, should also be considered in the differential diagnosis (Bizzi et al., 2016).

Medical Bruising Assessment

Age:

Sex:

Ethnicity:

Where are the bruises located?

What is the approximate size of the bruises?

What color are the bruises?

How often do new bruises appear?

How long do the bruises take to heal?

Have you experienced bleeding from other sites?

Are you experiencing any of the following?

Are you currently taking any medications?

Do you have a history of any of the following?

How often do you consume alcohol?

Have you experienced mucosal bleeding?

Do you experience frequent nosebleeds?

Have you noticed blood in your urine or stool?

Do you have any known platelet or clotting disorders?

Do you have a history of anemia or low iron levels?

Have you had any recent infections or illnesses?

Do you have any autoimmune conditions?

Have you experienced unexplained swelling or joint pain?

Do you take any dietary supplements, including herbal medications?

In cases where spontaneous bruising is accompanied by other systemic symptoms, such as fatigue or unexplained weight loss, malignancies such as leukemia should be ruled out. Symptoms like these can be indicative of more severe underlying conditions, necessitating further investigation through blood tests and possibly bone marrow biopsy (Aisyi, 2024).

Overall, the initial approach to spontaneous bruising in adults should involve a detailed clinical history, physical examination, and appropriate laboratory investigations to identify the underlying etiology. This comprehensive evaluation is essential for guiding effective management and addressing any potential complications associated with the identified conditions.

Key Differentials for Spontaneous Bruising

Key Differentials for Adults Presenting with Spontaneous Bruising

Category	Differential Diagnosis	Key Features/Associated Symptoms	Further Workup
Hematologic Disorders	- Immune thrombocytopenia (ITP) - Leukemia - Aplastic anemia	- Petechiae, purpura - Fatigue, recurrent infections - Pancytopenia (in aplastic anemia)	- CBC with differential - Peripheral blood smear - Bone marrow biopsy if indicated
Coagulation Disorders	- Hemophilia (A or B) - von Willebrand disease - Acquired factor deficiencies (e.g., liver disease)	- Large joint/muscle hematomas - Prolonged bleeding with trauma - Jaundice or liver disease stigmata	- PT/INR, aPTT - von Willebrand panel - Factor activity assays
Vascular Causes	- Vasculitis (e.g., Henoch-Schönlein purpura) - Amyloidosis	- Palpable purpura, systemic symptoms (e.g., fever, arthralgia) - Chronic disease symptoms in amyloidosis	- Skin biopsy for immunofluorescence - Serum/urine protein electrophoresis
Medication-Induced	- Anticoagulants (e.g., warfarin, DOACs) - Antiplatelets (e.g., aspirin, clopidogrel)	- History of medication use - Increased bruising with minor trauma	- Medication review - PT/INR for anticoagulant monitoring
Nutritional Deficiencies	- Vitamin C deficiency (scurvy) - Vitamin K deficiency	- Corkscrew hair, gingival bleeding (scurvy) - Prolonged PT (vitamin K deficiency)	- Nutritional assessment - Plasma vitamin levels
Connective Tissue Disorders	- Ehlers-Danlos syndrome - Marfan syndrome	- Hypermobile joints, skin fragility, atrophic scars - Tall stature, lens dislocation (Marfan)	- Genetic testing if indicated
Infectious Causes	- Sepsis with disseminated intravascular coagulation (DIC)	- Fever, hypotension, multiorgan failure - Mucosal bleeding	- D-dimer, fibrinogen levels - Blood cultures
Systemic Diseases	- Chronic kidney disease - Liver failure	- Uremic platelet dysfunction (CKD) - Jaundice, ascites, spider angiomata (liver failure)	- Renal/liver function tests

References

Advenier, A., Marchaut, J., & Grandmaison, G. (2013). Neck pseudo-bruising secondary to acute aortic dissection. Medicine Science and the Law, 54(1), 54-57. https://doi.org/10.1177/0025802412473962
Aisyi, M. (2024). Unraveling copy number alterations in pediatric b-cell acute lymphoblastic leukemia: correlation with induction phase remission using MLPA. Asian Pacific Journal of Cancer Prevention, 25(7), 2421-2426. https://doi.org/10.31557/apjcp.2024.25.7.2421
Bizzi, F., Sciarretta, L., D'Alessandro, M., & Picco, P. (2016). A long-term psychological observation in an adolescent affected with Gardner Diamond Syndrome. Indian Journal of Psychological Medicine, 38(1), 74-77. https://doi.org/10.4103/0253-7176.175129
Desilets, A., Willett, K., Waller, D., & Barry, A. (2012). Risk of spontaneous bruising with concomitant use of nonsteroidal anti-inflammatory drugs and citalopram. Journal of Pharmacy Technology, 28(5), 204-207. https://doi.org/10.1177/875512251202800506
Echahdi, H., Hasbaoui, B., Khorassani, M., Agadr, A., & Khattab, M. (2017). Von Willebrand's disease: case report and review of literature. Pan African Medical Journal, 27. https://doi.org/10.11604/pamj.2017.27.147.12248
Enger, C., Bennett, D., Forssén, U., Fogarty, P., & McAfee, A. (2010). Comorbidities in patients with persistent or chronic immune thrombocytopenia. International Journal of Hematology, 92(2), 289-295. https://doi.org/10.1007/s12185-010-0636-3
Kazakov, D., Pavlov, G., & Stefanov, C. (2021). Ehlers-Danlos syndrome type IV - anaesthetic considerations. Folia Medica, 63(1), 153-155. https://doi.org/10.3897/folmed.63.e53968
Rashid, R., Mazumder, W., Karim, A., Begum, F., Islam, F., & Sonia, Z. (2020). Von Willebrand disease, a rare cause of massive upper GI bleeding: A case report. Bangladesh Journal of Child Health, 43(3), 188-191. https://doi.org/10.3329/bjch.v43i3.49581