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Nose Bleed


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Nose Bleed

  1. 1. Case Presentation Morning Report James Booth, MS4 University of Texas at Houston Medical School
  2. 2. CC: Nose Bleed <ul><li>HPI: This is a 55-year-old Hispanic woman with a two-year history of Wegener’s Granulomatosis who first began to notice bruising on her arms and legs 1 ½ months ago. Her Rheumotogist was on maternity leave and she did see a doctor at that time. 1 week ago, she noticed that her gums were bleeding while she brushed her teeth. She now presents with a nose bleed that started spontaneously this morning and she has not been able to stop the bleeding. ~2 yrs ago, she had a period of 2 weeks in which she had multiple nose bleeds that resolved spontaneously without seeing a doctor. Otherwise, no similar past history of bleeding or bruising. Mildly fatigued today but otherwise feeling good. </li></ul>
  3. 3. <ul><li>PMH: </li></ul><ul><li>Wegener’s Granulomatosis for 2 years </li></ul><ul><li>s/p Cytoxan tx >1 month ago </li></ul><ul><li>Dyspepsia </li></ul><ul><li>PSH: </li></ul><ul><li>Ex-lap ~30 yrs ago for stab wound </li></ul><ul><li>Right foot surgery ~6 yrs ago following trauma-related fracture </li></ul><ul><li>Medications: </li></ul><ul><li>Prednisone 50mg BID </li></ul><ul><li>Pantoprazole 40mg Daily </li></ul><ul><li>Calcium Citrate </li></ul>
  4. 4. <ul><li>Allergies: NKDA </li></ul><ul><li>Social History: </li></ul><ul><li>Smoked 1-2 cigarettes occasionally during holidays but quit 5 years ago. No history of EtOH or drug use. Works as a housekeeper. Visited El Salvador 5 weeks ago. No known sick contacts. </li></ul><ul><li>Family History: </li></ul><ul><li>No known bleeding disorders, diabetes or cancer. </li></ul>
  5. 5. <ul><li>ROS: </li></ul><ul><li>General – No fevers/chills. No recent illness. No wt changes. </li></ul><ul><li>Skin – Other than the bruises, no rashes. No pruritus. </li></ul><ul><li>HEENT – No HA. No visual changes. No congestion. No history of thyroid problems. </li></ul><ul><li>CV – No chest pain, palpitations or syncope. </li></ul><ul><li>Lungs – No SOB or cough. </li></ul><ul><li>GI – No N/V/D/C. No bloody stools. </li></ul><ul><li>GU – No dysuria. No hematuria. Positive polyuria. </li></ul><ul><li>MS – No arthritis or stiffness. No joint swelling. </li></ul><ul><li>Neuro – No weakness. No dizziness. “Numbness” in both feet for ~2 yrs. </li></ul><ul><li>Psych – History of depression ~1yr ago, no medications. Mood has significantly improved since then. No anxiety. </li></ul>
  6. 6. <ul><li>Vitals: HR 77, BP 122/71, RR 18, Temp 98.2 </li></ul><ul><li>Physical Exam: </li></ul><ul><li>General – Pleasant, obese, NAD </li></ul><ul><li>Skin – Multiple ecchymoses on upper and lower extremities ranging from 2-6cm in diameter, no petechia, no jaundice </li></ul><ul><li>Head – NCAT, nontender </li></ul><ul><li>Eyes – PERRLA, no scleral icterus, no conjunctival pallor </li></ul><ul><li>Nose – No bleeding/discharge, no septal deviation </li></ul><ul><li>Mouth/Throat – MMM, clear oropharynx, no petechiae </li></ul><ul><li>Neck – supple, nontender, no LAD, no thyroid masses </li></ul><ul><li>Lungs – CTA, no wheezes or crackles </li></ul><ul><li>CV – RRR, normal S1 S2, no murmurs, no rubs </li></ul><ul><li>Abdomen – soft, nontender, (+)BS, </li></ul><ul><li>no hepatosplenomegaly, no masses appreciated </li></ul><ul><li>Extremities – no clubbing/cyanosis/edema, 2+ pulses, </li></ul><ul><li>no joint swelling, no tenderness </li></ul><ul><li>Neuro – CNs II-XII intact. 5/5 strength. Somewhat decreased sensation in both feet to light touch. </li></ul>
  7. 7. <ul><li>Labs: </li></ul><ul><li>Plt </li></ul><ul><li>Hg 12.0 </li></ul><ul><li>Hct 35.1 </li></ul><ul><li>WBC 10.9 </li></ul><ul><li>(N88 L6 M5 E0 B0) </li></ul><ul><li>Na 137 </li></ul><ul><li>K 3.6 </li></ul><ul><li>Cl 103 </li></ul><ul><li>CO2 26 </li></ul><ul><li>BUN 14 </li></ul><ul><li>Cr 0.7 </li></ul><ul><li>Gluc 89 </li></ul>PT 10.1 INR 0.95 PTT 25.4 AST 16 ALT 20 Alk Phos 71 Albumin 4.1 Total Bili 0.2 Direct Bili <0.05 Ca 9.3 5
  8. 8. <ul><li>Peripheral Smear: </li></ul><ul><li>Normocytic, normochromic anemia </li></ul><ul><li>Thrombocytopenia </li></ul>
  9. 9. <ul><li>Bone Marrow Bx: </li></ul><ul><li>35% cellularity (mildly decreased cellularity) </li></ul><ul><li>Orderly trilineage maturation </li></ul><ul><li>Adequate megakaryocytes present </li></ul><ul><li>1+ iron stores present </li></ul>
  10. 10. <ul><li>IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) </li></ul><ul><li>Pathogenesis : </li></ul><ul><li>Peripheral destruction and/or inhibition of production of platelets by auto-antibodies. </li></ul><ul><li>Two Basic Criteria for Diagnosis: </li></ul><ul><li>(1) Otherwise normal CBC, diff, and peripheral smear </li></ul><ul><li>(2) No conditions or medications to account for the thrombocytopenia* </li></ul><ul><li>*Wegener's granulomatosis is more commonly associated with thrombocytosis (>400,000) rather than thrombocytopenia. </li></ul>
  11. 11. <ul><li>IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) </li></ul><ul><li>- Unlike children, spontaneous remissions are unusual in adults. </li></ul><ul><li>There is no accepted platelet count that defines an indication for initial treatment. </li></ul><ul><li>Data shows that among patients with initial platelet counts above 30,000 to 50,000, fewer than 10 percent develop more severe thrombocytopenia and require treatment after three to seven years of follow-up. </li></ul><ul><li>Factors to consider when deciding to treat: </li></ul><ul><ul><li>Presence or absence of severe or life-threatening bleeding </li></ul></ul><ul><ul><li>Risks for trauma from the patient's age, occupation, and lifestyle </li></ul></ul><ul><ul><li>Medical conditions and medications </li></ul></ul>
  12. 12. <ul><li>IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) </li></ul><ul><li>Treatment: </li></ul><ul><li>Typically, prednisone 1 mg/kg PO given as a single daily dose. The duration of treatment is determined by the platelet count response and tapering is commonly 4-6 weeks. </li></ul><ul><li>Dexamethasone 40mg PO or IV daily X 4-8 days in another option. This therapy may be repeated in cycles of 14-28 days. </li></ul><ul><li>IVIG and anti-Rh (for Rh+ patients) increase the platelet count in most patients with ITP within several days. These are used in the acute setting and do not thought to induce long-term remission. </li></ul><ul><li>Splenectomy has been the traditional second-line treatment for those who fail initial therapy. Data suggests 2/3rds of splenectomy patients recover and maintain a normal platelet count. Patients typically have a platelet count above 50,000 before surgery. Defer for several weeks after initial diagnosis. </li></ul><ul><li>Platelet transfusions for life-threatening bleeding (which is rare in ITP) </li></ul>
  13. 13. <ul><li>Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. AU George JN; Woolf SH; Raskob GE; Wasser JS; Aledort LM; Ballem PJ; Blanchette VS; Bussel JB; Cines DB; Kelton JG; Lichtin AE; McMillan R; Okerbloom JA; Regan DH; Warrier I SO. Blood 1996 Jul 1;88(1):3-40. </li></ul><ul><li>Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol 2003; 120:574. </li></ul><ul><li>Immune thrombocytopenic purpura. AU Cines DB; Blanchette VS SO N. Engl J Med 2002 Mar 28;346(13):995-1008. </li></ul><ul><li>Morbidity and mortality in adults with idiopathic thrombocytopenic purpura. AU Portielje JE; Westendorp RG; Kluin-Nelemans HC; Brand A. Blood 2001 May 1;97(9):2549-54. </li></ul><ul><li>Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. AU Cheng Y; Wong RS; Soo YO; Chui CH; Lau FY; Chan NP; Wong WS; Cheng G. N Engl J Med 2003 Aug 28;349(9):831-6. </li></ul>