Welcome ApplicantsFebruary 4th, 2011

The Child With Pain

Single Joint Involvement

Multiple Joint Involvement

With Fever

Septic arthritis/Osteomyelitis

Sympathetic arthritis

Foreign body with infection

Traumatic arthritis

Soft Tissue infection

Rheumatic Diseases

Reactive arthritis

Toxic synovitis

Diskitis

Sarcoidosis

Hemoglobinopathy

Malignancies

Without Fever

Trauma

Mechanical derangement

Rheumatic Diseases

Toxic synovitis

Avascular necrosis

Subacuteosteomyelitis

Diskitis

Hemoglobinopathy

Reflex sympathetic

dystrophy

Malignancies

Psychogenic pain

With Fever

Bacterial infections

Sepsis

Viral infections

Lyme disease

Reactive arthritis

Rheumatic diseases

Post immunization

Immune deficiencies

Serum sickness

Inflammatory bowel

disease

Sarcoidosis

Familial Mediterranean fever

Malignancies

Without Fever

Rheumatic diseases

Joint hypermobility

Growing pains

Post immunization

Immune deficiencies

Guilain-Barre

Lyme Disease

Fibromyalgia syndrome

Chronic fatigue syndrome

Psychogenic pain

Malignancies

Evaluation of Bleeding DisorderAm I dealing with a bleeding disorder?What is the clinical phenotype?Is it congenital or acquired?Systemic disease or drug causing

exacerbation?

Am I dealing with a bleeding disorder?

With bruisingTrauma is most commonAbuse is more common than hemophilia

Am I dealing with a bleeding disorder?Bruising

Typical areas: boney protuberances of extremities More pronounced, more numerous, recurrent Larger than quarter-size Associated hematoma Intramuscular hematoma or hemarthrosis Out of proportion to mechanism

Am I dealing with a bleeding disorder?Epistaxis

ER visitBoth nostrils simultaneouslyAssociated with other signs of bleedingFamily history of similar bleeding

Am I dealing with a bleeding disorder?Menorrhagia

Associated with anemiaFrequent pad changes (<q2hrs)Menses >7days

Am I dealing with a bleeding disorder?Surgical Bleeding

Uncontrolled bleeding in surgical fieldOther sites (drains, lines)Unexpected need for transfusion

What is the clinical phenotype?Primary hemostasis

(platelets, vWF, vessel)Easy bruisabilityPetechiaeEpistaxisMenorrhagiaSurgical wound

oozing

Coagulation factor

(Hemophilia)HematomasHemarthrosisDelayed surgical

bleeding

Inheritance PatternsHemophilia

X-Linked

Glanzmann thrombastheniaFactor XIII

Autosomal recessive

Von WillebrandAutosomal Dominant

Acquired Bleeding AbnormalityUnderlying medical illness

Liver diseaseVitamin K deficiencyDisseminated intravascular coagulation

Medications

Lab EvaluationScreening Studies

CBC, smear, PT, PTT, Bleeding time/PFAPT: extrinsic and common pathwaysPTT: intrinsic and common pathways

Factor XIII can have normal PT and PTTIncidental prolonged PTT

Lupus Anticoagulant

HemophiliaX-LinkedFemale carriers may be symptomaticPresentation

CircumcisionWith ambulation

Labs: prolonged PTTHemophilia A: Factor VIII

1:5,000Hemophilia B: Factor IX

1:30,000

Hemophilia: TreatmentInfusion of factor concentratesProphylacticallyMinor hemorrhage

50% correctionMajor hemorrhage

100% correction

What’s going on?16y/o athlete with h/o hemophiliaCc: Left groin pain, limpNo h/o traumaExam: decreased sensation anterior L thigh

Painful extension L hipDecreased strength with flexion L hip

What to do?3y/o with h/o hemophiliaWas playing on back of couch and fell to floor

Struck headActs drowsy