About This Page
This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
The Bottom Line
- Bleeding or bruising requires separation of local trauma from systemic haemostasis disorders — platelet/vessel problems cause mucocutaneous bleeding, while factor problems cause deep tissue, joint and delayed bleeding.
- Start with acuity and stability before narrowing the differential.
- Use CBC with differential, smear, coagulation studies and targeted tests according to the presentation pattern.
- Escalate urgently for abnormal smear, systemic red flags, major bleeding, sepsis, thrombosis, neurologic symptoms or suspected malignancy.
- Management is cause-directed and should follow Canadian transfusion, thrombosis and cancer diagnostic pathway principles.
Approach to the Presentation
Bleeding & Bruising is approached as a clinical presentation rather than as a single diagnosis. Begin by assessing stability, bleeding or thrombosis risk, infection/sepsis features, medication exposures, pregnancy status where relevant, and systemic red flags. Then use the pattern of the abnormality — CBC lineage, smear morphology, coagulation pathway, node distribution, spleen size, or VTE pre-test probability — to select focused investigations. For MCCQE1, the safest answer is usually the one that identifies must-not-miss disease while avoiding reflex treatment of an isolated laboratory value.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Disseminated intravascular coagulation (DIC) | must-not-miss | Sepsis, trauma, obstetric catastrophe or malignancy; bleeding from lines, purpura, organ dysfunction, thrombosis and bleeding together. | Low platelets, prolonged PT/aPTT, low fibrinogen, high D-dimer, schistocytes. |
| Anticoagulant-associated major bleeding | must-not-miss | Warfarin, DOAC, heparin, renal impairment, interactions, GI/intracranial bleeding, fall or trauma. | Medication history, INR for warfarin, anti-Xa/drug-specific assays where available, CBC/creatinine; CT if head injury. |
| Acute leukemia or marrow failure | must-not-miss | Bruising with fatigue, fever, infections, bone pain, gingival hypertrophy, lymphadenopathy or hepatosplenomegaly. | CBC with differential and smear showing blasts or pancytopenia; urgent haematology. |
| Thrombotic thrombocytopenic purpura (TTP) | must-not-miss | Purpura, thrombocytopenia, microangiopathic haemolysis, neurologic symptoms, renal injury, fever; incomplete pentad is common. | Schistocytes, haemolysis labs, severe thrombocytopenia; ADAMTS13 confirms but treatment must not wait. |
| Immune thrombocytopenia (ITP) | common | Isolated thrombocytopenia with petechiae, bruising or epistaxis; otherwise well; post-viral or autoimmune context. | CBC/smear showing isolated thrombocytopenia without blasts or schistocytes. |
| von Willebrand disease | common | Lifelong mucocutaneous bleeding, epistaxis, heavy menstrual bleeding, dental/surgical bleeding, family history. | vWF antigen/activity and factor VIII; aPTT may be normal or mildly prolonged. |
| Medication-related platelet dysfunction | common | Aspirin, NSAIDs, clopidogrel, SSRIs, alcohol or uremia; mucosal bleeding with normal platelet count. | Medication history; platelet function testing rarely needed acutely. |
| Liver disease with coagulopathy | common | Easy bruising, spider naevi, ascites, jaundice, alcohol use, hepatitis risk, splenomegaly. | Liver tests, INR, platelet count, albumin, bilirubin and ultrasound if indicated. |
| Vasculitis / palpable purpura | less common | Palpable purpura on legs, arthralgia, abdominal pain, renal findings, systemic symptoms. | Urinalysis, creatinine, inflammatory markers, skin biopsy when needed. |
| Inherited factor deficiency (haemophilia A/B) | rare | Male patient, hemarthroses, deep muscle haematomas, delayed post-procedure bleeding, family history. | Isolated prolonged aPTT correcting on mixing study; low factor VIII or IX. |
Red Flags & Key History
Symptoms
Hematemesis, melena, intracranial symptoms, airway bleeding or rapidly expanding haematoma
Fever, hypotension, confusion, oliguria or sepsis features with bleeding — possible DIC
Neurologic symptoms with thrombocytopenia or haemolysis — possible TTP
Fatigue, recurrent infections, bone pain, weight loss or night sweats — leukemia/marrow disease
Recent anticoagulant, antiplatelet, NSAID, antibiotic, herbal or chemotherapy exposure
Lifelong epistaxis, heavy menses, dental bleeding or family history — inherited bleeding disorder
Signs
Shock, pallor, orthostasis or altered mental status
Petechiae or wet purpura in the mouth — severe platelet-type bleeding
Palpable purpura with renal findings or abdominal pain
Hepatosplenomegaly or lymphadenopathy
Hemarthrosis or deep muscle bleeding — factor deficiency pattern
Approach to Investigation
First-line
CBC with differential and platelet countDetermines whether bleeding is associated with thrombocytopenia, anaemia, leukocytosis or pancytopenia.
Peripheral smearPlatelet clumping, blasts, schistocytes, dysplasia, giant platelets.
PT/INR, aPTT, fibrinogen, D-dimerCore coagulation screen; DIC pattern is prolonged PT/aPTT, low fibrinogen, high D-dimer and low platelets.
Creatinine/eGFR, liver tests, pregnancy test where relevantRenal dysfunction affects platelet function/DOAC clearance; liver disease affects clotting factor synthesis.
Second-line
vWF antigen/activity and factor VIIIFor recurrent mucocutaneous bleeding, heavy menstrual bleeding or family history.
Mixing study and factor assaysFor unexplained prolonged aPTT or PT; correction suggests deficiency, non-correction suggests inhibitor/lupus anticoagulant.
Haemolysis screen and ADAMTS13If thrombocytopenia plus schistocytes/haemolysis suggests TTP; do not delay treatment.
Specialist
Urgent imaging for site-specific major bleedingCT head, CT angiography, endoscopy or procedural imaging depending on bleeding site.
Haematology/transfusion medicine consultationMajor bleeding, suspected TTP/DIC, inherited disorder, severe thrombocytopenia, factor inhibitor or complex reversal.
Management Principles
MCC bleeding/bruising objective + Canadian Blood Services transfusion guidance + Choosing Wisely Canada1
Immediate management of significant bleeding
- ABCs, direct pressure/source control, IV access, type and crossmatch, blood product resuscitation guided by severity.
- Stop anticoagulants/antiplatelets where safe and identify last dose, renal function and indication.
- Use local measures including pressure, packing, suturing, tranexamic acid where appropriate and urgent procedural control.
2
Treat by mechanism
- Platelet-type bleeding: manage thrombocytopenia/platelet dysfunction; platelet transfusion for severe bleeding or very low platelets where appropriate.
- Warfarin major bleeding: vitamin K plus prothrombin complex concentrate according to local protocol.
- DIC: treat underlying cause and support with platelets/plasma/cryo only when bleeding or procedure requires it.
3
Non-major bleeding and prevention
- Avoid unnecessary plasma or platelet transfusion for mild lab abnormalities without bleeding.
- Review medications and avoid NSAIDs/aspirin unless clearly indicated.
- Arrange outpatient haematology workup for suspected inherited bleeding disorder after acute control.
Complications & Pitfalls
- Pattern matters: petechiae and epistaxis are platelet/vessel clues; hemarthroses and delayed bleeding are factor clues.
- Do not miss DIC: bleeding plus sepsis, trauma, obstetric catastrophe or malignancy needs urgent treatment.
- Do not transfuse plasma for a mildly elevated INR in a non-bleeding patient.
- Check the medication list: anticoagulants, antiplatelets, NSAIDs, SSRIs, alcohol and herbals are common traps.
- TTP is time-sensitive: plasma exchange pathways are lifesaving.
MCCQE1 Exam Tips
- 1Mucocutaneous bleeding = platelet/vessel/vWF; deep bleeding or hemarthrosis = coagulation factor disorder.
- 2Petechiae + low platelets = thrombocytopenia pathway; hemarthrosis + isolated prolonged aPTT = haemophilia pathway.
- 3DIC labs: low platelets, prolonged PT/aPTT, low fibrinogen, high D-dimer.
- 4von Willebrand disease is the most common inherited bleeding disorder and often presents with heavy menstrual bleeding.
- 5A normal platelet count does not exclude platelet dysfunction — aspirin/NSAIDs and uremia are common causes.
- 6Major anticoagulant bleeding: identify the agent and reverse/support according to local protocol.
practicetest your knowledge on bleeding & bruisingApply what you've learnt with MCCQE1-style questions from the iatroX Q-Bank — haematologic & oncologic and beyond.
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