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All posts with tag: "heme"

PEM Questions

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You are seeing an 8-year-old boy for prolonged nosebleed last night and this morning. Last night it happened on the right nares, and this morning on the left nares. Dad is a nurse and held pressure until the bleeding stopped, and there is currently no bleeding. Exam shows temp 37.5, HR 90, RR 24, BP 94/56. Exam is negative for lymphadenopathy, hepatosplenomegaly, or pallor. There is a small amount of dried blood in the left nares. His parents did not notice any rash, but on exam with the patient undressed you notice a few petechiae on the ankles and across the lower abdomen. There are no purpura. Laboratory values are: WBC 10.3, diff 40% polys, 45% lymphs, 8% monos; Hgb 13, Hct 39, Platelets 1. Lytes, LFTs, BUN/Cr, are all normal. There are no inpatient beds available, so management will begin in the ED. 

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You are seeing a 13 year old girl for menorrhagia. This is her second menses ever, and she has been having to change her pad every 2 hours for 7 days. Her physical exam is unremarkable except for some mild tachycardia and ongoing vaginal bleeding. She has not had any surgeries, but she does recall a nosebleed episode that lasted 15 minutes, and she does endorse easy bruising. She is not taking any medications and has no significant past medical history. There is no known family history of a bleeding disorder, and she has one older brother who is healthy. 

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You are seeing a 16 month old toddler who is a very picky eater. He mostly eats 32 oz of whole milk per day, and a few finger foods. His parents feel that he looks pale – you check a hemoglobin and find that they are correct! It is 4.8 g/dL. He is active and playful, hemodynamically stable, and has no evidence of bleeding. He has no petechiae, purpura, hepatosplenomegaly, or mass, and the remainder of his blood counts (WBC, platelets) are normal. 

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You are evaluating a term neonate for hyperbilirubinemia. The baby was sent home at 36 hours of life with a bilirubin measurement of 7.0, and has returned at 72 hours of life due increased jaundice. 

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You are seeing a 3 year old girl who was discharged from the hospital a week ago. At that time, she presented with fever, intermittent polyarthralgias, and an evanescent salmon pink rash. She was diagnosed with new onset systemic juvenile idiopathic arthritis, treated with ibuprofen, and initially did well. She now presents with unremitting fever and rash, bruising, petechiae, gum bleeding, hepatosplenomegaly, and lethargy. Labs reveal elevated transaminases, ferritin, LDH, and triglycerides, but a low ESR.

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old who is slowly improving from a bout of acute gastroenteritis manifested by fever, vomiting, diarrhea, and abdominal pain that started 5 days ago. The parent is concerned that he remains less active and appears pale. Vital signs are temperature 37.7, HR 135, RR 24, BP 110/60, O2 sat 99% on room air. Point of care hemoglobin is 6.5 g/dL. [yop_poll id="155"]
(Click the link to comment and to vote - voting not working through email, sorry!) Pediatric patients with sickle cell anemia have a higher susceptibility to becoming infected with which organism? [yop_poll id="136"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old toddler is brought in for decreased energy and “not acting right.” On exam, the child is noted to be pale, mildly tachypneic, and has a flow murmur. She is afebrile. Her point of care hemoglobin is 3.2 g/dL, and additional history reveals that she is a very picky eater and drinks five 8-oz bottles of milk per day and takes in little else. A full CBC and iron studies are sent to the lab. [yop_poll id="129"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 12 year old girl with PMH of sickle cell disease complicated only by 2 lifetime hospitalizations for vasoocclusive pain crisis. She presents with fever, cough, and increasing shortness of breath over the last 2 days. Her mother was recently diagnosed with influenza. CXR shows a right upper lobe infiltrate. Vital signs are: temperature 38.8, HR 130, RR 30, BP 110/60, O2 sat 96% on room air. Hemoglobin is 9 g/dL, which is the patient’s baseline. [yop_poll id="114"]
(Click the link to comment and to vote - voting not working through email, sorry!) A full term infant with no birth complications and no known risk factors for hyperbilirubinemia complications, discharged early at 36 hours of life, presents to the ED on day of life #4 with jaundice that just started on the day of presentation. Serum bilirubin is 15, all unconjugated. The baby is exclusively breastfed and having 4 wet diapers per day. [yop_poll id="110"]  
(Click the link to comment and to vote - voting not working through email, sorry!) A 19 year old otherwise well-appearing man presents with 2 days of headache, anorexia, tactile fever (but afebrile in the ED), and 1 day of palpable purpura on bilateral lower legs. Which of the following is true? [yop_poll id="92"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19 year old man presents 4 hours after leaving his dentist office from wisdom tooth extraction. He has been having bleeding from the socket that will not stop for the last 2 hours. His dentist office is now closed and no one is answering the phone. He has no prior history of excessive bleeding and is not taking any medications. He is hemodynamically stable, and on exam you see a clot in the socket surrounded by a steady ooze of blood, which the patient spits out onto a napkin every minute or so. [yop_poll id="73"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6yo girl presents with palpable purpura of both legs for 2 days. She has not had any fever and is well appearing. Her labs, including CBC, electrolytes, BUN, Creatinine, and ESR are normal. She does not complain of any pain. Her vital signs are temperature 37.5 C, HR 90, RR 20, BP 90/45. She has no abdominal tenderness, vomiting, respiratory difficulty, joint pain or swelling, and her urination has been normal. Her stool guaiac is negative. [yop_poll id="62"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="53"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 year old girl with heavy prolonged menses x 10 days who appears pale to her parents. She had menarche at age 11, and has had heavy irregular menses since then. She actually feels that her menses is slowing down and she is currently using 1-2 pads per day. She has never had any other bleeding. Her HR is 90, and BP 100/50. Her hemoglobin is 9 and her MCV is 65. [yop_poll id="50"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6 week old ex-30 4/7 weeks twin A male infant was seen at an outside clinic because his parents felt that his heart was beating faster than his twin sibling’s and was found to have a hemoglobin of 7.9 g/dL. The clinic referred him in to the ED for blood transfusion and hematology consultation. The heart rate is 165 bpm on the monitor, blood pressure is 74/40, cap refill is < 2 seconds, and color is pink. The remainder of his CBC is normal, and the patient is afebrile, feeding and growing well, and asymptomatic except for his heart rate. Reticulocyte count is 4.77%. [yop_poll id="20"]

Tips and Tricks

Iron deficiency anemia can be seen in toddlers that have switched to cow's milk (typically at age 1 yr) from formula. If the child's diet is nearly exclusively cow's milk, a severe anemia can slowly develop due to iron deficiency and chronic subclinical GI blood loss. Toddlers should not drink > 20 oz milk / day; their diet must contain a variety of foods. Only severe cow's milk-associated anemia (Hgb < 5 g/dL) requires transfusion; otherwise diet modification and iron supplementation suffices. When transfusing hemodynamically stable patients who developed their anemia chronically, transfusion aliquots should be smaller and slower to avoid TACO (transfusion-associated circulatory overload). A good rule of thumb is: transfusion aliquot = Hemoglobin amount in mL/kg over 3-4 hours, so a child with a hemoglobin of 2.5 would receive 2.5 mL/kg PRBCs over 3-4 hours (instead of the typical pediatric transfusion aliquot of 10 mL/kg).

Controversies

You are seeing a 6 week old ex-full term infant who is breastfeeding exclusively, having 6 wet diapers per day, 4 or more soft seedy stools per day, growing well, and no fever. Baby has been jaundiced since 1st week of life, and while it is not worse, parents come in because it is prolonged. Jaundice is to the level of the chest, and transcutaneous bili is 10. [poll id="12"]

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