A PALE CHILD with history of widespread bruising

History

Sarah is a 4-year-old girl who is referred to the paediatric day unit by her GP with a 2-day history of widespread bruising. She has also had two nosebleeds in the preceding 24 hours. There are no known injuries, although her mother says she is quite ‘hectic’, especially when playing with her younger brother. They both had a cold and a sore throat 2 weeks previously. She is otherwise very well. There is no significant past medical or family history and
she is on no medication.

Examination

Sarah is drawing pictures and is cheerful and cooperative. She has no dysmorphic features. Her height and weight are on the 25th centiles. There is no jaundice and she is afebrile. She is pale and clinically anaemic with a few <1.0 cm lymph nodes in the cervical and inguinal regions. There is widespread bruising mainly on her limbs but no evidence of active bleeding. There is no hepatosplenomegaly. Her pulse is 96 beats/min and both heart sounds are normal. She has a grade 2/6 ejection systolic murmur. Examination of the respiratory system is normal.