Case 21: Bruising

Front 1

Petechiae and purpura

Back 1

• trauma
  
• platelet deficiency
  
• coagulation abnormalities
  
• vascular fragility
  
• combinations of the above
  

Front 2

Hepatomegaly?

Back 2

• Causes
  
• Examination
  
• Measurement
  

Front 3

Causes of hepatomegaly

Back 3

• result of inflammation
  
• infiltration
  
• accumulation of storage products
  
• obstruction
  

Front 4

Examination of hepatomegaly

Back 4

• placing child in supine position with knees and neck flexed
  
• ask child to breath deepy
  
• palpate RLQ and gradually move upward
  

Front 5

Signs/symptoms of HSP?

Back 5

• non-thrombocytopenic purpura
  
• 1/3 of children have renal involvement
  
• arthritis
  
• colicky abdominal pain
  
• two thirds of patients have URI
  

Front 6

Complications of HSP

Back 6

• chronic renal failure
  
• end stage renal disease
  
• occasionally hospitalization for abdominal pain, GI bleeding, intusseception, and renal involvement.
  

Front 7

Treatment of HSP?

Back 7

controversial

early corticosteroids in hospitalized children

Front 8

ITP

Back 8

• caused by binding of antiplatelet antibody to platelet surface
  
• leads to removal and destruction of platelets in spleen and liver
  

Front 9

HSP talking to parents

Back 9

prognosis: lasts a month or so

follow up: repeat urine samples to monitor for resolution of kidney inflammation and follow BP

instructions:

seek urgent medical attention if:

• stomach pain sudden or severe
  
• blood in stool
  
• vomiting
  
• puffy
  

Front 10

What is intussusception?

Back 10

Intussusception occurs when a proximal segment of bowel invaginates or telescopes into the distalsegment adjacent. The accompanying mesentery becomes entrapped, causing vascularcompression and eventual ischemia.

Front 11

Intussusception presention

Back 11

Paroxysms of severe abdominal pain with inconsolable cryingPassage of "currant jelly" stool containing blood and mucusPalpation of a "sausage-shaped" mass in the right abdomen

Front 12

Diagnosis/treatment of Intussusception?

Back 12

US initial eval

then reduce by air or hydrostatic pressure

Front 13

Complications of HSP

Back 13

intestinal bleed

kidney involvement

Front 14

HSP recurrence

Back 14

30%

Front 15

Emergent findings

Back 15

• Altered mental status
  
• Respiratory distress/respiratory depression
• Mottled skin/cyanosis

Front 16

urgent manifestations

Back 16

fever, pallor, pain

Front 17

Key questions to ask patient

Back 17

"What do you think is going on?"

"What do you think is going on?"

"What worries you about what is happening?"

"What do you think might happen next?"

Front 18

How to examine lymph nodes?

Back 18

• size and location
  
• distribution
  
• texture
  
• mobility
  

Front 19

Causes of splenomegaly?

Back 19

• Hemolysis
  
• Malignancy
  
• Storage diseases
  
• Systemic inflammatory diseases
  
• Congestion
  

Front 20

Hemolysis

Back 20

• Epstein-Barr virus
  
• Cytomegalovirus
  
• Bacterial sepsis
• Endocarditis

Front 21

Malignancy

Back 21

leukemia

lymphoma

Front 22

Systemic inflammatory disease

Back 22

Systemic lupus erythematosus

Juvenile idiopathic arthritis

Front 23

Congestion

Back 23

complication of portal hypertension

Front 24

Spleen

Back 24

s helpful to have the patient lie supine and flex his or her legs torelax the abdominal muscles. In this position, it may be possible to gently "bounce" anenlarged spleen, which is located somewhat posteriorly, forward using a lifting maneuveralong the left flank.Alternatively, having the patient roll onto his or her right side may rotate the spleen anteriorlyinto a palpable position.As in the liver exam, having the patient inhale deeply to lower the diaphragm, or palpatingfirst in the pelvis then moving superiorly may facilitate detection of an enlarged spleen.

Front 25

DDx for bruising and leg pain?

Back 25

• Coagulation disorder
  
• Henoch-Schönlein purpura (HSP)
  
• Idiopathicthrombocytopenic purpura (ITP)
  
• Leukemia
  
• Viral infection
  
• Bacterial endocarditis
  
• Drug reaction
  
• Meningococcal septiciemia
  
• Rocky Mountain spotted fever (RMSF)
  
• Systemic lupus erythematosus(SLE)
  

Front 26

Coagulation disorder?

Back 26

may present with petechiae or superficial bruising, but more oftenpresents with easy bruising in deep tissues or hemarthrosis

Front 27

Hemophilias?

Back 27

painful bleed into joints

Front 28

HSP

Back 28

Often presents in an otherwise well appearing child with bruising and leg pain (due toarthritis).In roughly 50% of cases, a URI precedes the diagnosis of HSP

Front 29

ITP

Back 29

Often presents with asymptomatic petechiae.A nonspecific URI precedes ITP more than 50% of the time

Front 30

Leukemia

Back 30

Usually presents with constitutional symptoms such as fever, malaise and weight loss.Bone pain is also a common presentation of leukemia in children. The pain results frominfiltration of the bone marrow by malignant cell.Petechiae can be caused by thrombocytopenia due to bone marrow replacement bymalignant cells.

Front 31

Viral infection

Back 31

petechial rash

low grade fever

Front 32

Bacterial endocarditis

Back 32

fatigue, fever, weight loss, petechial rash, fever

Front 33

Drug reaction

Back 33

reaction to medication

distribution diffuse

Front 34

Menigoccal septicemia

Back 34

• petechiae
  
• purpura
  
• ill appearing
  
• require emergent care
  

Front 35

RMSF

Back 35

rash is often petechial

starts on extremities before moving centrally

fever is hallmark

Front 36

SLE

Back 36

• variable
  
• fever
  
• malaise
  

Front 37

DDx of rash and leg pain?

Back 37

HSP

ITP

Leukemia

Front 38

HSP

Back 38

involves lower extremities

periarticular vasculitis

Front 39

ITP

Back 39

not associated with splenomegaly

Front 40

Leukemia

Back 40

• bone pain
  
• splenomegaly
  
• lymphadenopathy