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Approach to bruising and bleeding

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Bleeding into a closed space: head, airway and neck, retroperitoneum: image and correct in parallel
    • Platelets under 10-20 with wet purpura in the mouth: spontaneous CNS bleeding territory
    • Fever plus new cytopenias with fragments on the film: think TTP or DIC, both are hematology-now calls
    • Anticoagulated and bleeding: name the drug, the dose, the timing, and the reversal in one breath

  2. History that discriminates

    • Pattern is the diagnosis: mucocutaneous ooze (platelets or von Willebrand) versus joints and muscles (factors)
    • Lifelong (with dental extractions and surgeries as natural experiments) versus new-onset
    • The full drug list, honestly: anticoagulants, antiplatelets, NSAIDs, recent antibiotics, alcohol
    • Family history in the bleeding disorders that travel in families
    • Systemic clues: weight loss and sweats (marrow disease), liver disease, kidney disease

  3. Examination

    • Distribution and stage of bruises; petechiae where gravity and pressure put them
    • The mouth for wet purpura: the sign that upgrades urgency
    • Lymph nodes, spleen, liver: the marrow's neighbors
    • Joints for hemarthrosis in the factor story

  4. Problem representation

    A previously well woman with three days of petechiae, nosebleeds, and gum ooze, platelets 8, otherwise normal counts and film (points at ITP) versus a man on rivaroxaban with dark stools and a hemoglobin two grams below last month (points at anticoagulant-facilitated GI bleeding).

  5. Differential, by mechanism

    Platelet number

    • ITP
    • Drug-induced
    • Marrow failure or infiltration
    • Hypersplenism
    • DIC and TTP consuming them

    Platelet function / vessel

    • Uremia
    • Antiplatelet drugs
    • von Willebrand disease
    • Senile purpura and steroids

    Coagulation factors

    • Anticoagulants
    • Liver disease
    • Vitamin K deficiency
    • Hemophilia
    • DIC

  6. Investigations

    • CBC with a FILM (fragments, blasts, clumps), PT/INR, aPTT, fibrinogen
    • Renal and liver panels: two organs that bleed by proxy
    • Mixing studies split deficiency from inhibitor when the aPTT stands alone
    • Group and save early when bleeding is active

  7. Interpretation

    • Isolated thrombocytopenia with a normal film in a well patient reads as ITP: a diagnosis of exclusion made confidently
    • Fragments plus thrombocytopenia is never ITP: that pairing is TTP or DIC and changes the tempo to hours
    • A normal platelet COUNT with a platelet-pattern bleed points at function: uremia, drugs, von Willebrand

  8. Next steps

    • Active serious bleeding: local control, reversal agents by drug, transfusion by deficit, and the source hunt in parallel
    • ITP with counts above the danger floor and dry skin only: often observation; steroids when treatment is due
    • Never transfuse platelets into suspected TTP or heparin-induced thrombocytopenia without hematology on the line

Connected

AlgorithmWhen hemoglobin falls tooApproachThe GI versionTopicThe frame this hangs on

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