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 HEMAT.....a 14 yo boy withleft knee pain  



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Author7 Posts
  #1

case: A 14 yo boy recently began playing baseball in a local little league.He noted left knee pain after his first practice.he does not remember any trauma to the knee,but he did slide into second base.His knee began hurting him that evening and he treted it with elevation & ice.It improved slightly, but 2 days later he noted the onset of swelling with discoloration over the skin.He denies fever or chills or any h/o nose or gum bleeding.VS: BP---110/70mm Hg, pulse---70/min, temp---98.6 F.PE-----clear lungs,regular heart rate & rhythm, no hepatosplenomegaly.His left knee isswollen and discolored an dhe is unable to bear wt. There r no petechiae noted.
CBC---WBC==500/mm3, Hb—14 G/DL,platelets---260,000/mm3
PT—12 SECS, PTT—75SECS, fibrinogen----350mg/dl, plain film of knee---osteosrthritis and articular fibrosis seen. Aspiration of knee-----clotted blood, gm stain neg, culture neg.BT---normal.
The best next investigation which wud take us to our conclusion abt. the diagnosis is----------
1. mixing study
2. echo
3. spine xray
4. MRI knee
5. blood cultures

which of the following is not associated with this abnormality???
1.hemarthrosis
2. life threatening bleeds
3.iron deficiency anemia
4.compression of local nerve groups
5.hematuria




  #2

IS IT MENISCAL TEAR....?

THEN MRI-KNEE JOINT WOULD BE INFORMATIVE......


  #3

I THINK AS THE PTT IS INCREASED THERE IS SOMETHING WRONG WITH THE CLOTTING FACTORS ...... :roll: :roll:


  #4

i think its haemophilia.......


  #5

>> Mixing study

>> Iron Deficiency anemia


  #6

IF IT'S HEMOPHILIA OR CHRISTMAS DISEASE (FACTOR IX DEFICIENCY) THEN IT'S MIXING STUDIES THAT WILL BE DIAGNOSTIC...

AND THE PATIENT WOULD NOT HAVE HEMATURIA..... :roll: :roll:


  #7

PERRRRRRRFECT NUBIE......... grin grin !!!!!!!!!! And shirishand DPS, also have thought in a right direction, approaching the answer almost....... grin grin

ANSWERS ARE….1 (mixing study), 3 (iron deficiency anemia)
The pt. Presents with trauma induced , delayed bleeding in the deep tissue, which is suggestive of coagulopathy as compared with immediate mucosal bleeding seen with platelet dysfunction.This is further supported by absence of petechiae.
Pt. has abnormal PTT, normal PT, suggesting problem xclusively of intrinsic cascade .In a young male we must consider hemophilia due to either factor VIII or IX deficiency or presence of inhibitor to factor VIII.But, since factor VIII is a longer molecule and as such, mutations are 5 times more common with that, we shud consider that more.
Here, a mixing study wud allow us to come to a conclusion about the diagnosis……….whether it’s deficiency(correction of defect can be seen with mixing study) or inhibitor(no correction of defect after mixing study).
Pt.s with hemophilia often have significant degenerative ds. From repeated bleeding an dmay have neuropathy from compression of local nerve grps.Hemarthrosis, hematuria which is self limiting, life threatening bleeds involving oropharynx and CNS, can occur, but IDA is not a common complication coz bleeding is usually internal with reabsorption of iron…..





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