Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting concern
Bleeding and bruising overview
Primary symptom
First noticed date and context
Progression
Spontaneous
Minor trauma associated
Recurrent pattern
Onset
Onset
Sudden
Gradual
Single episode
Recurrent episodes
Provocation/Palliation
Provoking factors
Trauma
Exercise
Valsalva
Recent procedure
New medication exposure
Relieving factors
Local pressure response
Prior response to antifibrinolytic
Quality
Bleeding phenotype
Mucocutaneous bleeding
Deep tissue bleeding
Joint bleeding
Bruise phenotype
Small pinpoint lesions
Large ecchymoses
Palpable lesions
Region/Radiation
Bleeding sites
Epistaxis
Gingival bleeding
Hemoptysis
Hematemesis
Melena
Hematochezia
Hematuria
Vaginal bleeding
Ocular bleeding
Bruising distribution
Extremities
Trunk
Face
Unusual locations
Severity
Severity markers
Soaking pads
Prolonged epistaxis
Large expanding hematoma
Syncope
Near syncope
Prior hemostatic support
Prior transfusion
Prior factor concentrate
Prior hospital admission
Timing
Timing
Continuous bleeding
Intermittent bleeding
Nocturnal symptoms
Cyclic with menses
Time course clues
Post procedure delayed bleeding
Recent viral illness timing
Associated symptoms
Associated symptoms
Fever
Weight loss
Night sweats
Fatigue
Dyspnea
Chest pain
Headache
Focal neurologic symptoms
Abdominal pain
Arthralgia
Dark urine
Bleeding history baseline
Prior hemostasis history
Dental procedure bleeding
Surgical bleeding
Postpartum bleeding
Menorrhagia history
Childhood easy bruising
Prior diagnoses
Known bleeding disorder
Prior thrombocytopenia
Prior abnormal INR
Alarm Features
Immediate threats
Life threatening bleeding
Airway bleeding
Suspected intracranial hemorrhage
Hemodynamic instability
Massive gastrointestinal bleeding
Massive postpartum bleeding
Immediate escalation triggers
If SBP < 90 mmHg, resuscitation bay
If HR > 120, resuscitation bay
If altered mental status, immediate CT head
If ongoing active bleeding, activate massive transfusion protocol per local protocol
High risk populations
High risk context
Anticoagulant use
Recent surgery
Known liver failure
Pregnancy
Postpartum
Cancer
Immunocompromise concerns
Chemotherapy exposure
Stem cell transplant history
High risk exam patterns
Exam red flags
Petechiae with fever
Purpura with neurologic symptoms
Jaundice with bleeding
Large tense hematoma
High risk bleeding patterns
Mucosal bleeding with platelets very low
Deep tissue bleeding with prolonged aPTT
High risk lab thresholds
Lab danger thresholds
Platelets < 10 x10^9/L
Platelets < 20 x10^9/L with active bleeding
INR > 3 on warfarin
Fibrinogen < 1.5 g/L
Hemolysis microangiopathy triggers
Schistocytes on smear
Rising creatinine
Medications
Antithrombotics
Anticoagulants
Warfarin
Apixaban
Rivaroxaban
Edoxaban
Dabigatran
Heparin
Low molecular weight heparin
Antiplatelets
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
Bleeding risk medications
Common contributors
NSAIDs
SSRIs
SNRIs
Systemic corticosteroids
Valproate
Chemotherapy agents
Drug induced thrombocytopenia exposures
Heparin exposure
TMP SMX exposure
Beta lactam exposure
OTC supplements
Supplements and herbals
Fish oil
Vitamin E
Ginkgo
Garlic supplements
Ginseng
Recent changes
New start
Dose increase
Missed doses
Contraindications to typical therapies
Contraindication screens
TXA contraindication history
DDAVP contraindication history
History of thrombosis
Diet
Intake patterns
Recent diet change
Reduced intake
Vomiting
Diarrhea
Hydration indicators
Poor oral intake
Orthostatic symptoms
Alcohol exposure
Alcohol exposure
Heavy episodic use
Daily use
Recent withdrawal
Micronutrients relevant to bleeding
Vitamin K intake
Reduced leafy greens
Prolonged antibiotics effect
Vitamin C intake
Restricted diet
Food insecurity concern
Review of Systems
Bleeding system review
Bleeding sites review
Epistaxis
Gingival bleeding
Easy bruising
Heavy menses
GI bleeding symptoms
Hematuria
Procedure related bleeding
Dental bleeding
Post injection bleeding
Constitutional and malignancy
Systemic symptoms
Fever
Weight loss
Night sweats
Fatigue
Infection symptoms
Sore throat
Cough
Dysuria
Autoimmune and vasculitis
Inflammatory symptoms
Arthralgias
Photosensitivity
Oral ulcers
Raynaud symptoms
Vasculitis symptoms
Palpable purpura symptoms
Neuropathy symptoms
Neurologic and cardiopulmonary
Neurologic symptoms
Headache
Confusion
Weakness
Vision changes
Cardiopulmonary symptoms
Dyspnea
Chest pain
Syncope
Collateral History and Family History
Collateral sources
Source and reliability
Family report
Caregiver report
Pharmacy record
Prior records
Safety context
Home supervision reliability
Concerns for coercion or violence
Family history bleeding
Inherited bleeding disorders
von Willebrand disease (D68.0)
Hemophilia A (D66)
Hemophilia B (D67)
Platelet function disorder
Clue history
Male relatives with bleeding
Postpartum hemorrhage in relatives
Family history hematologic disease
Hematologic conditions
Leukemia (C91.9)
Aplastic anemia (D61.9)
Thrombocytopenia history
Thrombosis history
Venous thromboembolism
Antiphospholipid syndrome (D68.61)
Risk Factors
Bleeding risk factors
Acquired bleeding risks
Liver disease
Chronic kidney disease
Malignancy
Sepsis
Iatrogenic risks
Recent surgery
Recent biopsy
Central line placement
Thrombocytopenia risks
Immune triggers
Autoimmune disease
Recent viral illness
Recent vaccination timing
Consumptive triggers
DIC risk context
TTP risk context
Coagulopathy risks
Vitamin K deficiency context
Poor intake
Malabsorption
Antibiotic exposure
Factor inhibitor risk context
Postpartum acquired hemophilia
Autoimmune disease
Special populations
Pregnancy and postpartum
Current pregnancy
Postpartum within 6 weeks
Pediatrics and adolescents
Growth and nutrition risk
Sports trauma exposure
Differential Diagnosis
Life threatening
Life threatening causes
Intracranial hemorrhage (I62.9)
Headache
Focal deficits
Anticoagulant exposure
Gastrointestinal hemorrhage (K92.2)
Hematemesis
Melena
Hemodynamic instability
DIC (D65)
Sepsis context
Low fibrinogen
Elevated D dimer pattern
TTP (M31.1)
Thrombocytopenia
Hemolysis with schistocytes
Neurologic symptoms
Acute leukemia (C95.00)
Cytopenias
Blasts on smear
Infection symptoms
Common
Common causes
ITP (D69.3)
Isolated thrombocytopenia
Mucocutaneous bleeding
Medication related bleeding
Anticoagulants
Antiplatelets
NSAIDs
von Willebrand disease (D68.0)
Menorrhagia
Mucosal bleeding
Family history
Liver disease coagulopathy (K74.60)
Jaundice
Elevated INR
Less common
Less common causes
Hemophilia A (D66)
Hemarthrosis
Deep muscle hematomas
Acquired hemophilia A (D68.311)
New isolated prolonged aPTT
Postpartum timing
Platelet function disorder (D69.1)
Normal platelet count
Mucosal bleeding
Scurvy (E54)
Corkscrew hairs
Gum changes
Restricted diet
IgA vasculitis (Henoch Schonlein) (D69.0)
Palpable purpura
Abdominal pain
Hematuria
Mimics and pitfalls
Mimics
Senile purpura
Sun exposed forearms
Fragile skin
Mechanical bruising
Sports contact
Occupational trauma
Pitfalls
Normal PT and aPTT does not exclude platelet function disorder
Mild thrombocytopenia can still bleed with platelet dysfunction
Past Medical History
Relevant conditions
Comorbidities affecting hemostasis
Cirrhosis
Chronic kidney disease
Heart valve disease
Atrial fibrillation
Autoimmune disease
SLE (M32.9)
Antiphospholipid syndrome (D68.61)
Prior bleeding episodes
Prior events
Prior transfusion
Prior hospital admission for bleeding
Prior intracranial bleed
Baseline bleeding tendency
Lifelong easy bruising
New onset bleeding tendency
Procedures and devices
Prior procedures
Recent dental extraction
Recent surgery
Devices
Mechanical valve
LVAD
Hemodialysis access
Physical Exam
Initial stability
General appearance
Toxic appearance
Pallor
Diaphoresis
Vital sign patterns
Orthostasis
Persistent tachycardia
Hypotension
Skin and mucosa
Skin bleeding findings
Petechiae
Purpura
Ecchymoses
Hematoma
Mucosal bleeding findings
Active epistaxis
Gingival bleeding
Oral petechiae
Head and neurologic
Neurologic screening
Level of consciousness
Focal deficits
Gait abnormality
Eye findings
Conjunctival pallor
Subconjunctival hemorrhage
Cardiopulmonary
Perfusion assessment
Capillary refill delay
Cool extremities
Cardiorespiratory exam
Tachycardia
Signs of heart failure
Abdomen and GU
Abdominal exam
Tenderness
Hepatomegaly
Splenomegaly
Flank and retroperitoneal clues
Flank ecchymosis
Groin ecchymosis
MSK and joints
Joint bleeding findings
Warm swollen joint
Reduced range of motion
Muscle bleeding findings
Compartment firmness
Pain out of proportion
Pelvic exam considerations
Vaginal bleeding evaluation context
Pregnancy status known
Heavy ongoing bleeding
Lab Studies
Core hemostasis labs
Initial labs
CBC with platelet count
Peripheral smear review
PT and INR
aPTT
Fibrinogen
D dimer
Metabolic context labs
CMP including AST ALT bilirubin
Creatinine
Albumin
Type and transfusion readiness
Transfusion preparation
Type and screen
Crossmatch if active bleeding
Pregnancy testing when applicable
Urine pregnancy test
Serum beta hCG if uncertain
Interpretation patterns
Thrombocytopenia pattern
Isolated thrombocytopenia with normal smear
Thrombocytopenia with schistocytes
Thrombocytopenia with blasts
Coagulation pattern
Isolated prolonged PT
Isolated prolonged aPTT
Both PT and aPTT prolonged
Expanded testing
von Willebrand evaluation
vWF antigen
vWF activity
Factor VIII activity
Factor deficiency or inhibitor evaluation
Mixing study
Specific factor assays
Bethesda inhibitor assay
Platelet function testing
Platelet function evaluation
Platelet function analyzer
Platelet aggregation studies
Uremic platelet dysfunction clues
Elevated urea context
Normal platelet count with mucosal bleeding
Pitfalls and limitations
Common pitfalls
EDTA platelet clumping pseudothrombocytopenia
Hemodilution effect after large IV fluids
Timing limitations
Early DIC can have near normal PT
vWF levels can rise with stress and inflammation
Imaging
Scoring Systems
Risk and diagnostic scores
PLASMIC score for TTP pretest probability
When to use
When not to use
4T score for HIT pretest probability
When to use
When not to use
ISTH DIC overt score
When to use
Limitations
MRI
MRI indications
Suspected spinal epidural hematoma
Suspected muscle hematoma with neurovascular compromise
MRI constraints
Unstable patient limitation
Implanted device contraindications
CT
CT head
If new neurologic symptoms, immediate noncontrast CT head
Lower threshold with anticoagulant exposure
CT abdomen pelvis
Suspected retroperitoneal hemorrhage
Suspected solid organ bleeding after trauma
Ultrasound
Focused bedside ultrasound
FAST exam when unstable with suspected intraabdominal bleeding
IVC assessment as adjunct to volume status
Pelvic ultrasound when applicable
Pregnancy with bleeding
Suspected retained products postpartum
Special Tests
Bedside hemostasis interventions
Local hemostasis measures
Direct pressure response
Topical vasoconstrictor response
Epistaxis bedside management adjuncts
Topical TXA local protocol dependent
Anterior packing response
Hematology directed diagnostics
Mixing study interpretation
Correction suggests factor deficiency
No correction suggests inhibitor
ADAMTS13 testing
Supports TTP diagnosis
Do not delay treatment if high suspicion
Procedural diagnostics
Bone marrow evaluation triggers
Pancytopenia
Blasts on smear
Endoscopy pathway triggers
Overt GI bleeding with instability
Significant hemoglobin drop
ECG
Indications in bleeding presentations
ECG indications
Syncope
Chest pain
Significant tachycardia
Monitoring triggers
Active hemorrhage with hemodynamic instability
Massive transfusion protocol activation
High risk patterns
Ischemia patterns
ST elevation
ST depression
T wave inversion
Arrhythmia patterns
Atrial fibrillation with rapid ventricular response
Ventricular tachycardia
Assessment
Hemostasis localization
Primary hemostasis disorder pattern
Petechiae
Mucosal bleeding
Immediate bleeding after procedure
Secondary hemostasis disorder pattern
Deep hematomas
Hemarthrosis
Delayed bleeding after procedure
Severity and risk stratification
Severity stratification
Minor bruising without mucosal bleeding
Clinically significant nonmajor bleeding
Major bleeding with hemodynamic compromise
Complications to exclude
Intracranial hemorrhage
Retroperitoneal hemorrhage
Ongoing GI bleeding
Working diagnoses
Working diagnosis candidates
ITP (D69.3)
Isolated thrombocytopenia
No hemolysis on smear
Anticoagulant associated bleeding (D68.32)
Timing with last dose
Renal function impact
DIC (D65)
Triggering condition
Low fibrinogen pattern
Uncertainty documentation
Alternative diagnoses
TTP (M31.1)
HIT (D75.82)
Acute leukemia (C95.00)
Next decision points
Need for urgent reversal
Need for urgent hematology consultation
Plan
First 5 minutes critical patient
Immediate stabilization
Continuous monitoring
Two large bore IV lines if unstable
Oxygen if hypoxemia
Hemorrhage control priorities
Local pressure and hemostatic measures
Activate massive transfusion protocol per local protocol
Diagnostic sequencing
Initial diagnostics
CBC smear PT INR aPTT fibrinogen
Type and screen
Targeted diagnostics
If schistocytes, PLASMIC score and TTP pathway
If heparin exposure, 4T score and HIT testing
Transfusion thresholds
Red blood cell transfusion
Consider transfusion if hemoglobin < 70 g/L in stable hospitalized adults
Higher threshold if ongoing ischemia or shock
Platelet transfusion
If platelets < 10 x10^9/L, consider prophylaxis based on context
If active bleeding, consider transfusion if platelets < 50 x10^9/L
If intracranial hemorrhage, consider higher platelet target per specialist guidance
Coagulopathy correction
Fibrinogen replacement
If fibrinogen < 1.5 g/L with bleeding, cryoprecipitate per local protocol
Recheck fibrinogen after replacement
Vitamin K
Vitamin K IV 5 mg
Vitamin K IV 10 mg
Anticoagulant reversal
Warfarin associated major bleeding
Four factor PCC per weight based protocol
Vitamin K IV 10 mg
Dabigatran associated major bleeding
Idarucizumab IV 5 g
Hemodialysis consideration if renal failure and severe bleed
Factor Xa inhibitor associated major bleeding
Andexanet alfa local protocol dependent
Four factor PCC local protocol dependent
Platelet dysfunction therapies
DDAVP
DDAVP IV 0.3 mcg per kg over 20 to 30 minutes
Avoid in hyponatremia risk
Antifibrinolytic
Tranexamic acid IV 1 g
Repeat dose IV 1 g after 8 hours local protocol dependent
Disease specific pathways
TTP suspected
If high suspicion, initiate emergent hematology pathway
Plasma exchange urgency
ITP suspected
If significant bleeding, corticosteroid initiation per guideline
IVIG consideration in severe bleeding
Consultation
Specialty consultation triggers
Hematology for unexplained thrombocytopenia or coagulopathy
Surgery or interventional radiology for uncontrolled bleeding source
OB GYN for heavy uterine bleeding
Reassessment loop
Reassessment timing
Repeat vitals every 15 minutes if unstable
Repeat CBC and coagulation labs after major intervention
Escalation triggers
If rising transfusion requirement, ICU
If new neurologic symptoms, immediate CT head
Disposition
ICU criteria
ICU indications
Hemodynamic instability requiring vasopressors
Massive transfusion protocol activation
Suspected intracranial hemorrhage
High risk hematology emergencies
TTP suspected
DIC with active bleeding
Inpatient admission criteria
Admission indications
Platelets < 20 x10^9/L with bleeding
New severe coagulopathy
Need for ongoing transfusion
Monitoring needs
Serial hemoglobin trend
Serial neurologic checks
Observation pathway
Observation candidates
Stable vitals
Controlled bleeding source
Clear outpatient follow up within 24 to 72 hours
Observation exclusions
Unreliable follow up
High risk medication that cannot be safely held
Discharge criteria
Discharge requirements
No ongoing bleeding
Stable hemoglobin trend
Platelets stable and not critically low
Follow up timing
Hematology follow up within 72 hours if new thrombocytopenia
Primary care follow up within 7 days
Discharge Instructions
Copy discharge instructions
Summary
You were seen for unexplained bruising or bleeding
Your tests today suggest a bleeding tendency that needs follow up
Medications
Avoid NSAIDs unless specifically instructed
Take prescribed medicines exactly as directed
Do not restart blood thinners unless your clinician tells you to
Activity
Avoid contact sports until cleared
Use soft toothbrush
Follow up
Follow up with your clinician within 1 to 3 days if labs were abnormal
Arrange hematology follow up if recommended
Return now
Any severe headache
Any new weakness
Trouble speaking
Fainting
Vomiting blood
Black stools
Heavy vaginal bleeding
Blood in urine
Bleeding that does not stop with 10 minutes of pressure
References
Guidelines and decision tools
Reference set
American Society of Hematology guideline for immune thrombocytopenia, 2019
American Society of Hematology guideline review and update process for immune thrombocytopenia, 2024
AABB International Guidelines for Red Blood Cell Transfusion, 2023
American College of Cardiology Expert Consensus Decision Pathway on management of bleeding in patients on oral anticoagulants, 2020
International Society on Thrombosis and Haemostasis disseminated intravascular coagulation scoring guidance, 2001
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.