Bruising Flashcards
OSOCRATES
Open question- what has been going on
Site- where ae the bruises/ how many
Onset- when did you first notice the bruises/ how has it progressed
Character- describe the bruises/ are they large or like pinpricks
Radiation- do they cover other areas of the body
Associated features- see later
Timing- have you suffered from easy bruising before
Exacerbating factors- any recent bumps or injuries
Severity- how is it affecting you/ have you been particularly ill and tired recently
NB- don’t forget non-accidental injury (domestic abuse)
Bleeding History
Do you tend to bleed for long periods when cut
Are your periods heavy/ did you bleed a lot after giving birth/ any previous surgical complications
Do you get regular nosebleeds
Is there ever blood in your stools or urine
Have you ever had any bleeding into your joints or muscles
Systems Review
Constitutional- FWAR
Lymphadenopathy- any lumps in your neck or anywhere else
Arthralgia/ myalgia- any aches or pains in your joints/ muscles
Infections- do you get infections regularly, have you had any recently
Meningitis- any neck stiffness/ headache
Patient on warfarin
Attended their INR clinics (dose may need reducing)
Taken any recent antibiotics (potentiates its effects)
Simple Uncomplicated Trauma
Bruise preceded by an obvious trauma of appropriate force with local tenderness
Common locations include the anterior aspect of lower legs and the forearms
Less likely if the bruise is on the back, buttocks, upper arm or abdomen. It is also less likely benign if found in a child less than 9months old (less mobile)
NB- steroids/blood thinners can predispose to bruising
Thrombocytopenia
Many causes, including bone marrow failure, hypersplenism, haematological malignancy, uraemia and autoimmune disorders
Poor platelet function often results in petechiae and mucosal bleeding
Lymphadenopathy and recurrent infections may suggest leukaemia
Haemophilia A and B
Defects of factors VIII and IX, respectively; usually presents in childhood
Hallmark symptoms of haemarthrosis and muscle haematomas
Severity depends on the level of functioning factor VIII/IX
Von Willebrand’s Disease
This the most common inheritable bleeding tendency, affecting up to 1% of people. It is inherited in an autosomal dominant fashion
Patients mainly complain of mucosal bleeding, although prolonged bleeding after surgery isn’t uncommon
Senile Purpura
Advanced age results in a decreased level of collagen, predisposing to bruising
The bruises here are typically large and dark. Th e overlying skin is thin and fragile. Th ese are usually found on extensor surfaces and forearms
Vitamin K Deficiency
In a new-born child, this should be considered
It is possible that the child may not have been given vitamin K after birth
In adults, due to liver disease or malabsorption with features of jaundice, history of alcohol abuse, steatorrhea and weight loss
Collagen Abnormality
Abnormalities of the vessel walls and surrounding tissues can predispose to bleeding, e.g. Ehlers–Danlos or Marfan’s syndrome
Skeletal involvement, cardiac involvement and ophthalmological involvement
Features include hyperextendable joints, tall stature and excess skin elasticity
Henoch-Schonlein Purpura
Typically affects younger children with a preceding URTI The rash looks very similar to bruises and starts on the back of the legs and buttocks or anywhere pressure is exerted, such as sock tops.
There may be associated abdominal pain, bloody diarrhoea, joint pain and in severe cases symptoms of renal failure
Investigations for Easy Bruising
FBC, LFTs, clotting profile and peripheral blood smear
Bleeding time
Mixing studies and factor + inhibitor assay
Platelet antibody assay
Bone marrow biopsy
Urine analysis
Patients perspective
Feelings
Impact on life
Ideas
Concerns
Expectations
PMH
Ask about blood disorders and previous malignancies
