A 4-year-old Latino male presents with a significant bruise on his face and a nosebleed that will not stop. The injury happened the day before when he and another child collided in the playground. Initially, a large bruise formed on his face (Figure 1) and he had a nosebleed. The nosebleed stopped. His parents picked him up and brought him home. Prior to this incident he had never had any other bleeding symptoms. He is not circumcised and has never had surgery. He has two older sisters, 6 and 9 years old. The 6 year old has had some easy bruising and nosebleeds that are mild in nature. The 9 year old has no bleeding symptoms. There are no other family members with bleeding symptoms.
Later in the evening, he starts having a nosebleed again and it continues for several hours despite the parents' attempts to stop it with pressure. Due to the continued bleeding, he is brought to the emergency room.