100 Cases in Clinical Medicine

Haematology

CASE 17: EASY BRUISING

History

A 36-year-old woman presents to her general practitioner (GP) complaining of spont-
aneous bruising mainly on her legs. The bruising has been noticeable over the last 4–6
weeks. She cannot remember any episodes of trauma. In addition her last two menstrual
periods have been abnormally heavy, and she has suffered a major nosebleed. She other-
wise feels well, and is working full time as a secretary. There is no significant past med-
ical history. She is married with one daughter aged 11 years. There is no family history of
a bleeding disorder. She is a non-smoker and drinks a small amount of alcohol socially.

Examination

On examination there are multiple areas of purpura on her legs and to a lesser extent on
her abdomen and arms. The purpuric lesions vary in colour from black–purple to yellow.
There are no signs of anaemia, but there are two bullae in the mouth and there is spontan-
eous bleeding from the gums. There are no retinal haemorrhages on funduscopy. Blood
pressure is 118/72 mmHg. Examination of the cardiovascular, respiratory and abdominal
systems is unremarkable.

Normal

Haemoglobin 10.9 g/dL 11.7–15.7g/dL

Mean corpuscular volume (MCV) 83 fL 80–99 fL

White cell count 4.3% 109 /L 3.5–11.0% 109 /L

Platelets 4 % 109 /L 150–440% 109 /L

Sodium 139 mmol/L 135–145 mmol/L

Potassium 4.3 mmol/L 3.5–5.0 mmol/L

Urea 5.4 mmol/L 2.5–6.7 mmol/L

Creatinine 76 &mol/L 70–120&mol/L

Glucose 4.3 mmol/L 4.0–6.0 mmol/L

Clotting screen: normal

Blood film: decreased platelets

INVESTIGATIONS

Questions

• What is the likely diagnosis?


• How would you further investigate and manage this patient?