Problem Rounds

1
Problem Rounds 8/3/06
13 yo with CC They made me come here
2
CC They made me come here HPI 13 yo HM
previously healthy presented to our Peds ED sent
by his doctor at juvenile hall during his routine
entrance exam. Pt states that 4 days PTA, pt was
served a warrant and arrested. He had been in
his high school parking lot and had been throwing
rocks at the nearby cars. Pt noted that he had
been in several fights with significant bruising,
although the patient had not paid any attention
to his bruises until pointed out to him during
his exam.
3
HPI Continued 3 days PTA, pt had a routine
intake exam by the doctor at juvenile hall, and
the doctor noted that the patient had a platelet
count of 11,000. A repeat count at juvenile hall
returned 5,000. (No other lab values were sent
with the patient) The patient was transferred to
WCH for further workup and care. Initially the
patient denied any symptoms, but on further
questioning the patient also recalled that he has
a history of nosebleeds which usually last a
long time, several minutes to one hour. He
denies any bleeding from his gums, hematuria,
hematochezia. He has never had any transfusions.
He denies fever, weight loss or recent
infections. Denies dizziness.
4
Take a moment to consider your differential
diagnosis
5
PMD Seen in medpeds clinic several months
ago. BirthHx Pt unable to tell us (mom not
present). PMHx Asthma, mild intermittent.
Cannot remember last time he needed his
inhaler. Hosp Pt has been hospitalized 5 years
ago when he broke his left wrist. SurgHx
None. Meds Pt has an albuterol inhaler but
cannot remember when or if hes ever used
it. Allergies NKDA.
6
FamHx Mom is 46, unsure about dad. 11 yo
brother and 19 yo sister. Dad died of cancer.
No family history of any blood disorders or easy
bruising. Mom has diabetes. Denies famhx of
asthma, cancer, htn, cad. SocHx Lives in 1
bedroom house with mom, stepdad and 2 siblings.
No pets or violence. Stepdad drinks
occasionally. HEADS Gets along well at home.
Going into 8th grade, likes math, gets Cs and
Ds. Denies tobacco and alcohol but has smoked
marijuana. No girlfriends, no sex, denies
SI. Immunizations UTD per patient. My mom has
the yellow card and its all filled out.
7
PE Awake, alert, mostly pleasant and
cooperative, non-toxic. HEENT NCAT, PERRLA, EOMI
bilat, no scleral icterus, no retinal hemorrhages
or papilledema on fundoscopic exam, nares
pink/clear w/o blood, moist mucus membranes,
oropharynx clear, no oral lesions. Neck Shotty
cervical lymph nodes, neck supple, trachea
midline, no thyromegaly, full ROM. Chest CTA
bilat without tachypnea or retractions, no
crackles, wheezes or rales. CV RRR s1s2 nml, no
murmurs, rubs, gallops. 2 radial and p. tibial
pulses. Abd Soft, NT, ND, NABS, no masses or
hepatosplenomegaly. GU Normal Tanner III male
with testes down, no masses. Ext No cyanosis,
clubbing or edema, lt2 sec cap refill Neuro CN
II-XII intact, 5/5 str, 2 DTRs, sensorium
intact, nml cerebellar fxn, all bilaterally.
Gait gross abnormal but difficult to access with
ankle restraints. Skin Multiple scattered
petechiae on back and axilla, 3 large ecchymoses
on R forearm, L inner thigh and R flank.
Otherwise dry, warm and intact. No jaundice or
rash.
8
Take a moment to consider your differential
diagnosis
9
WCH ED In the ER, vitals were T 97.8ºF, PR 86, RR
20, BP 119/71. Wt 61.8kg. Pain 3/10. Pt was
awake and comfortable, mostly cooperative. He
had been brought to the ED by a parole officer.
He was noted to have several ecchymoses on his
right flank, right arm and left thigh. He also
had scattered petechiae on his back as well as
few on his upper chest. He also had some shotty
lymph nodes in the anterior cervical chain
bilaterally (1-2). The remainder of the
physical exam was normal. (No jaundice, HSM,
rash) Upon further questioning, he reported that
4 days PTA he had fallen off his bike on his
right elbow, and he had also been in a fight and
was kicked on his right flank and left thigh. He
denied ever falling onto or otherwise
traumatizing his back.
10
(No Transcript)
11
Studies
12
Labs WBC 6.3, H/H 14.0/41.3, Plt 5. N49, L39,
M5, E6, bands lt10, giant platelets on smear.
(MCV 84, MCH 29, RDW 12) Repeat CBC WBC 6.5,
H/H 14.3/42.5, Plt 10. N51, L35, M6, E7. MPV
8.4. (MCV 84, MCH 28, RDW 13) U/A
clear/straw-colored, pH 6.0, SpGr 1.030, moderate
ketones. Remainder normal. CMP Na 141, K 3.7,
Cl- 105, HCO3- 23, BUN 18, Cr 0.7, Glu 99, Ca2
9.3, Mg2 2.1, Phos 5.3, Uric Acid 4.9, AlkP 243,
Prot 7.6, Alb 4.8, TBili 0.6, DBili 0.2, CK 68,
LD 245, AST 18, ALT 10 Ordered HIV, EBV, CMV,
ANA, Anti-DS, Anti-Smith, C3, C4, Anti-Ro and
Anti-La, Anti-RNP/Sm
13
Take a moment to consider your differential
diagnosis
14
Hospital Course IVIG overnight for ITP,
tolerated well. Had conference with mom and pt,
and pt understood the seriousness of his
condition. Day 2 labs WBC 5.2, H/H 13.5/40.3,
Plt 35. MPV 9.8 (MCV 85, MCH 28, RDW
12). VBG/lytes 7.34/52/35/28, Na 139, K 4.3,
Cl- 104 HIV neg, ANA neg, Anti-DS neg, C3 87, C4
137, Anti-Ro lt1, Anti-La lt1, Anti-RNP/Sm 1,
Anti-Sm 2. EBV/CMV pending. Seen by Peds Heme
/ Dr. Baehner if pt gets to goal platelet count
of 50,000 can go home.

15

• Thanks to Randall Chan who provided the write up
  and Dr. Baehner for assistance with the
  peripheral smear slide.