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Case Study: Unexplained Bruises

Nurses Article CSI   (2,531 Views | 8 Replies | 358 Words)

SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 56 Articles; 19,071 Profile Views; 357 Posts

What is the first thing you think of when you see bruises on a child?

Karen brings her daughter, Ann into the pediatric clinic stating, “She’s just been so tired lately. All she wants to do is sleep and she’s got no appetite. I’m worried.” Upon assessment, you discover bruises on the little girls’ arms and legs. Read on to see if you can get to the root of Ann’s problem.

Case Study: Unexplained Bruises
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If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us.  In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come.  You CAN post questions and post comments below.  BUT... Do NOT post your diagnosis guess below.

History of Present Illness: 

Ann is a 6 yo girl who is brought to the pediatric clinic. For the last week, her mother says she has been very tired, lacks energy, sleeps more than usual, and has not had much appetite. Upon assessment, you discover bruises on the little girls’ arms and legs that Karen can't explain. She says, "I had no idea those were there!" and looks embarrassed and worried. 

Past Medical History: 

Ann was full-term from an uncomplicated pregnancy and delivery. All immunizations are current. Ann had measles at age 3 yo.

Family History: 

Ann has one brother, age 8 years, who is in apparent good health. The maternal grandmother died at age 55 from rectal cancer. 

Social History: 

Developmental milestones on target. 

Medications: 

None

Allergies: 

NKDA

General Appearance: 

Alert, interactive, pale, height and weight normal for 6-yr-old

Vital signs:

  • BP 108/68 
  • HR 130/min 
  • RR 20/min 
  • T 98.7oF
  • HT 41 inches 
  • WT 37 lbs 

What are all the possible reasons for these signs and symptoms? Do you remember normal values for pediatrics vital signs? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? 

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school

12 Followers; 56 Articles; 19,071 Profile Views; 357 Posts

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DextersDisciple has 7 years experience as a BSN, RN.

314 Posts; 3,995 Profile Views

Can we have some labs please? Particularly CBC with diff and PT/INR. 

And do we know anything about dad/paternal family? May not be relevant but still.

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1 Follower; 1,858 Posts; 32,707 Profile Views

Please could we know:   CBC especially Hgb, Hct, platelet count; creatinine; BUN; urinalysis; who Ann lives with; who her primary caregiver/s are; what her normal routine is; who are the people that Ann spends time with or interacts with? Does Ann offer any information about whether she noticed her bruises or how they came about?  What was Ann's response when her mother was asked about her bruises? 

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 56 Articles; 357 Posts; 19,071 Profile Views

You got it! And THANK YOU for reading and commenting.

All vital signs normal except for heart rate, which is tachycardic. Why?

Vital signs:

  • BP 108/68 (normal for 6-year-old)
  • HR 130/min (normal 80-120/min)
  • RR 20/min (normal 20-28/min)
  • T 98.7oF
  • HT 41 inches (normal 41-43 inches)
  • WT 37 lbs (normal 40-50 lbs)

Review of Systems: only abnormal values presented

Skin: very pale, warm, and dry, ecchymoses on extremities, over the buttocks and lower left flank area. No rashes

HEENT: Petechiae of mucous membranes on gums and back of throat, cervical adenopathy, four palpable, non-tender, 2-cm lymph nodes in submaxillary chain

Abd: Liver and spleen enlarged

MS/Ext: Mild adenopathy in inguinal region, bilaterally  

Why are the liver and spleen enlarged? Explain the enlarged lymph nodes.

Laboratory Test Results:

  • Hb 7.7 g/dL 
  • Hct 23% 
  • RBC 2.8 million/mm3
  • WBC 13,100/mm3 
  • Neutrophils 59% 
  • Lymphocytes 26% 
  • Monocytes 3% 
  • Eosinophils 1% 
  • Basophils 0% 
  • Blasts 10% 
  • Platelets 29,000/mm3
  • AST 78 IU/L 
  • ALT 100 IU/L 
  • Total bilirubin 0.8 mg/dL 
  • Total protein 6.8 g/dL 
  • Alb 3.5 g/dL 
  • Ca 9.2 mg/dL 
  • Phos 4.0 mg/dL 
  • Uric acid 4.2 mg/dL 
  • PT 13 sec 
  • PTT 25 sec 
  • Glucose, fasting 90 mg/dL 

Why might AST and ALT be abnormal?

Would you order a spinal tap? If so, why?

What is the patient’s prognosis?

What treatment can you expect?

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tnbutterfly - Mary is a BSN, RN and specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

14 Followers; 130 Articles; 5,540 Posts; 200,057 Profile Views

Thanks for the update, SafetyNurse!  

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sirI has 30 years experience as a MSN, APRN, NP and specializes in Education, FP, LNC, Forensics, ED, OB.

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📢 Members are registering their dx guesses in the Help Desk! 📢

REMEMBER

Updates are added throughout this CSI. Submit a “dx guess” in the Admin Help Desk.

After an update, if you would like to amend your original guess, return to your ticket to submit additional information.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 56 Articles; 357 Posts; 19,071 Profile Views

And now the moment you've all been waiting for!

Drum roll please......

Laboratory Test Results (with normal values):

  • Hb 7.7 g/dL (12-15.5 g/dL)
  • Hct 23% (35-45%)
  • RBC 2.8 million/mm3 (4.6-6.1)
  • WBC 13,100/mm3 (4,800-10,800)
    • Neutrophils 59% (57-67)
    • Lymphocytes 26% (25-33)
    • Monocytes 3% (3-7)
    • Eosinophils 1% (1-4)
    • Basophils 0% (0.5-1%)
    • Blasts 10% (1-5%)
  • Platelets 29,000/mm3 (150-450,000)
  • AST 78 IU/L (0-35)
  • ALT 100 IU/L (7-56)
  • Total bilirubin 0.8 mg/dL (0.1-1.2)
  • Total protein 6.8 g/dL (6-8)
  • Alb 3.5 g/dL (3.4-4.7)
  • Ca 9.2 mg/dL (8.5-10.5)
  • Phos 4.0 mg/dL (2.5-4.5)
  • Uric acid 4.2 mg/dL (1.4-5.8 in females)
  • PT 13 sec (11-15)
  • PTT 25 sec (25-35)
  • Glucose, fasting 90 mg/dL (60-110)

Course of treatment:

Ann was immediately referred to a pediatric oncologist and admitted to the children’s hospital for workup.

Bone Marrow Aspirate: 

93% blasts, 3% erythroblasts, 4% all other cells

RT-PCR (+) for TEL-AML1 fusion gene with no other cytogenetic abnormalities

Chest X-ray:

Normal with no mediastinal mass

Lumbar puncture:

  • Spinal fluid clear and colorless
  • Opening pressure 90 mm H2O
  • Glucose 50 mg/dL
  • Total protein 18 mg/dL
  • No blasts present

Immunology:

(+) for cytoplasmic u heavy-chain proteins

Ann has acute lymphoblastic leukemia (ALL), the most common pediatric cancer. Sixty percent of all ALL cases occur in children, with a peak incidence at age 2 to 5 yr. A high circulating number of blasts, replacement of normal marrow by malignant cells, and the potential for leukemic infiltration of the CNS is caused by malignant transformation and uncontrolled proliferation of an abnormally differentiated, long-lived hematopoietic progenitor cell. Symptoms include fatigue, pallor, infection, bone pain, CNS symptoms (eg, headache), easy bruising, and bleeding. Examination of peripheral blood smear and bone marrow is usually diagnostic. Treatment typically includes combination chemotherapy to achieve remission, intrathecal and systemic chemotherapy and/or corticosteroids for CNS prophylaxis, and sometimes cerebral irradiation for intracerebral leukemic infiltration, consolidation chemotherapy with or without stem cell transplantation, and maintenance chemotherapy for up to 3 yr to avoid relapse. The (+) TEL-AML1 fusion gene is the most common chimeric fusion gene in childhood cancer. It is selectively associated with B cell precursor acute lymphoblastic leukemia.

A lumbar puncture can determine if the leukemia has spread to the cerebral spinal fluid (CSF). Knowing whether or not there is leukemia in the central nervous system helps determine the most appropriate treatment. All children with ALL receive medicine to treat or prevent leukemia of the central nervous system at the same time as the lumbar puncture at specific times during treatment.

Elevated transaminases are common at initial presentation of ALL and are likely due to hepatic injury from leukemic infiltrates. Conjugated hyperbilirubinemia at presentation may require treatment modification and dose reduction. A short course of steroids prior to initiation of induction chemotherapy appears to result in rapid resolution of the hyperbilirubinemia with subsequent ability to provide full dosing of induction chemotherapy.

Treatment:

On the 2nd day following admission, Ann was treated with irradiated/filtered platelets, packed red blood cells and allopurinol (what is the purpose of allopurinol prior to intensive chemo?)

Day 3 remission induction therapy orders

  • Prednisone 1 mg IV q wk x 4
  • Vincristine 1 mg IV q wk x 4
  • Asparaginase 3,600 units on chemotherapy days 3, 6, 9, 13, 16, 20
  • Intrathecal therapy with methotrexate on chemotherapy days 3 and 17

Prognosis:

Younger patients have a better prognosis. This is B-cell ALL, having a lower WBC count (< 30,000) when first diagnosed confers a better diagnosis. Ann had much less than 30,000). Abnormal numbers of chromosomes, abnormal structural changes in a chromosome, or certain molecular genetic changes in the chromosomes of leukemia cells may affect outcome and treatment. Note that the genetic changes referred to here are changes in the genes of the leukemia cells, not the child’s cells – most children with leukemia have completely normal genes.

Response to early treatment:

How well treatment works in the first 1 to 4 weeks of treatment may predict the leukemia’s overall response to treatment. This will be determined by examining the child’s blood or bone marrow regularly. Recent studies have shown that some children may need more intense treatment to improve the chance of a cure. This includes children whose cancer is not responding well to early treatment or those who have high levels of residual leukemia cells (cells remaining after treatment) at the end of remission induction. 

References

American Cancer Society, ALL

Merck Manual – Professional Edition

Abnormal liver transaminases and conjugated hyperbilirubinemia in ALL

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AN Admin Team has 50+ years experience.

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Here are the responses from members who came to the Admin Help Desk to submit their diagnoses for the 5th Case Study Investigation (CSI).

CONGRATULATIONS and DOUBLE THUMBS UP to those with the correct FINAL diagnosis!

3/2/20

Susie2310

Quote

👍👍 I haven't had the chance to go through all the labs but from what I can tell the diagnosis looks like Acute Lymphoblastic Leukemia (1st guess)or another type of Leukemia.  In Ann's case I understand her prognosis would be good.  Treatment is chemotherapy and/or radiation, and sometimes Stem Cell Transfer.

dream'n

Quote

👍 I'll go and try to answer, but I may be way wrong because I didn't research anything and this is totally off of the top of my head...she needs a bone marrow biopsy.  Maybe leukemia?

DextersDisciple

Quote

👍👍 Acute Lymphocytic Leukemia 

3/4/20

lsession2

Quote

👍 Leukemia 

 

NurseBlaq

Quote

:nurse: Answer: Von Willebrand disease

Thank you to all who participated. We hope you enjoyed the CSI.

CSI #6 is coming very soon! 🧐

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tnbutterfly - Mary is a BSN, RN and specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

14 Followers; 130 Articles; 5,540 Posts; 200,057 Profile Views

If you are viewing this for the first time after the answer was posted and didn't post your guess in the Admin Help Desk, did you guess the correct diagnosis?

Educators -

This would be a great exercise to share with your students to sharpen their assessment and diagnostic skills.  Please share the link with and encourage your students to see if they get the right diagnosis before they "read the last chapter of the book".  

Watch for the next CSI..

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