This document summarizes a medical case of a 5-year-old female presenting with excessive bruising over the past year. Examination revealed impressive bruising on her legs, elbows, and forehead, as well as diffuse hypermobility. Genetic testing confirmed a diagnosis of Ehlers-Danlos syndrome, which can cause easy bruising, hypermobility, and poor wound healing.

1. Why so many bruises?
A Primary Care Evaluation
Erica Labar, M.D., FAAP
Associate Medical Director
Assistant Professor of Pediatrics
University of Louisville Pediatrics Stonestreet
Louisville, KY
S

2. HPI
S BT is a 5 year old female who presents with a chief complaint of
bruises over her shins for 1 year
S During this time she has had relatively minor witnessed trauma
which resulted in large bruises that seemed to “last forever”
S One of these bruises in the area of her cheekbone lasted for so
long that an ultrasound was obtained for further evaluation
S The ultrasound was significant for resolving hematoma
S Because of the extensive bruising, CPS had been called twice to
investigate and had decided all bruising to be accidental

3. HPI
S Bruising has been centered over high contact areas,
(shins, elbows, forehead…)
S There has been no joint swelling, limp, mucosal bleeding,
or prolonged bleeding after scrapes or cuts

4. PMHx
S She was born at term via SVD without complications
S She has never been hospitalized or had surgery
S She is on no medications regularly and has not recently
taken NSAIDS/ASA/or other analgesics
S Developmental history was all wnl per parent

5. FHx
S There is a history of diabetes and HTN
S There is no history of hemophillia or “free-bleeders”
S Mother did report bleeding after a prolonged 8 hour
operation, but did not require transfusion or clotting
factors

6. Exam
S T- 98.9 HR- 90 RR- 20 B/P- 98/50 Wt- 40% Ht- 55%
S PE:
S Gen- aa, nad
S Heent- ncat, perrl, eomi, nares patent, op clear, mmm
S Cv- rrr, no m/g/r, pulses 2+ distally
S Resp- ctab
S Abd- s/nt/nd/+bsx4, no hsm
S Neuro- dtr’s 2+ u/l ext bilaterally, normal gait, sym strength/tone/bulk
S Lymph- shoddy cervical LAD only, no inguinal/axillary/supraclavicular
palpable

7. Exam
S Skin- impressive hematomas and ecchymosis on bilateral
pre-tibial regions, bilateral elbows, and forehead
S Skin was hyperextensible

8. Exam
S MSK- diffuse hypermobility was noted, exceptionally
prominent at the knees and elbows

9. Work Up
S Labs
S CBC/PT/PTT/INR
S ………
S ………..
S Referral to Hematology/Oncology for suspected Ehlers-
Danlos

10. Diagnosis & Discussion
S Genetic testing confirmed Ehlers-Danlos typexxx
S Most common manifestations include
S Easy bruising
S Hypermobility
S Poor wound healing
S ………………………………………………………..