Bleeding, bruising

Rationale

Minor localized bleeding or bruising is a common patient presentation and is often idiopathic in nature and/or self-limiting. However, excessive or prolonged bleeding or bruising can be associated with potentially serious underlying pathology, in which case urgent management may be required. Note that bleeding specifically related to major organ systems is covered under other Objectives (e.g., 6-1, 6-2, 112).

Causal Conditions

(list not exhaustive)

1. Mechanical bleeding (e.g., epistaxis) or traumatic localized bleeding (e.g., abrasion, laceration)
2. Idiopathic localized bleeding
3. Hemostasis disorders
   1. Platelet or blood vessel disorders (e.g., von Willebrand disease, collagen disorder, medication-induced disorder)
   2. Coagulation disorders (e.g., factor VIII or vitamin K deficiency, fibrinolysis)

Key Objectives

Given a patient with bleeding or bruising, the candidate will complete a relevant history and physical examination, order pertinent investigations to determine the most likely diagnosis, and initiate an appropriate management plan. In particular, the candidate should differentiate between minor self-limited causes of the bleeding versus potentially more serious hemostasis issues that may require urgent management.

Enabling Objectives

Given a patient with bleeding or bruising—whether localized or widespread, minor or major—the candidate will

1. list and interpret critical clinical findings, including those derived from
   1. an appropriate history and physical examination performed with particular attention to
      1. airway and hemodynamic status; and
      2. differentiation between various disorders of hemostasis and self-limited and/or idiopathic bleeding (e.g., epistaxis);
2. list relevant investigations and interpret the results of the investigations (e.g., complete blood count, coagulation studies); and
3. construct an effective initial management plan, including
   1. determining what immediate management is indicated (e.g., nasal packing, suturing, medication dosage adjustment, fluid resuscitation for hemodynamic instability);
   2. providing counselling and/or education on how to prevent future episodes; and
   3. determining whether specialized care is required.