History

CC:

“I have bruises on my arms and legs” x1 week

HPI:

Pt is a 15 year old female with no PMHx that presents to the outpatient pediatric office with her mom. Mom says that the school called telling her to bring the pt in due to complaints of bruising on bilateral arms and legs and pain in her knees. When speaking with the pt, she seemed to be very nonchalant and claimed that she bumps into things and falls over a lot due to the shoes that she wears. She says the bruising has been present for about a week and mom says she noticed them for the past 5 days. When asked about the pain in her knees, she said that was only because “I walked too much.” She denies current pain in her knees. Mom mentioned that pt had a similar experience at 8 years of age and was sent to the ER where they found nothing of concern. 

Pt denies pain, frequent nosebleeds, menorrhagia, bleeding gums, night sweats, fever, shortness of breath, fatigue, weight loss, drug use, recent infection/illness. 

Past Medical History: 

• Present concern: Bruising
• Past medical illnesses: None 
• Childhood illnesses: None 
• Immunizations: Up to date
• Past Surgical History: None
• Medications: None
• Allergies: None
• Family history: Mom (38), alive and well. No contact with dad. No siblings and no known significant family history.

Social History

• A.T. is a freshman in high school and lives in an apartment with her mom. They have no pets. She denies smoking, drinking alcohol and illicit drug use. Noone in the home smokes. She denies recent travel. Pt sleeps about 7 hours each night and feels rested. She participates in gymnastics after school. Her diet is balanced and consists of chicken, meat, fruits, vegetables and healthy carbs. 

Review of Systems:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Admits to bruising on bilateral arms and legs. Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies cyanosis, syncope, edema.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation.
• Genitourinary: Denies dysuria, urinary frequency, nocturia, urgency.
• Menstrual/Obstetrical: G0P0000, LMP 05/08/2024; denies menorrhagia 
• Musculoskeletal: Denies back pain, muscle pain, joint pain and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, head trauma, loss of strength.
• Hematologic: Admits to easy bruising. Denies anemia, easy bleeding and lymph node enlargement. 

Physical

• General:
  • The patient appears her stated age, well developed, well nourished and in no apparent distress.

Vitals:

• HR: 80 beats per minute, regular rate, rhythm and amplitude  
• RR: 16 regular rate and rhythm, unlabored
• T: not done 
• BP: 115/70 mm Hg
• Weight: 128 lb 
• Height: 63.5 in

Skin:

• Dozens of circular (approx 1-2 cm x 1-2 cm), yellow/green bruises on bilateral arms and legs. Warm and moist, good turgor. Nonicteric, no scars or tattoos noted.

Ears:

• Symmetrical and appropriate in size, in line with the eyes. No erythema, tenderness, swelling on external ears. No discharge, foreign bodies, inflammation in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Eyes:

• Symmetric, in normal position OU. No eyelid edema or discharge from eyes. Sclera white, cornea clear, conjunctiva pink.

Nose:

• Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Throat:

• Gingiva is pink and moist throughout with no spontaneous bleeding. Good dentition. No obvious dental caries noted. Tongue pink and well papillated, no masses or abnormalities. Oropharynx well hydrated with no injection, exudate, masses, lesions or foreign bodies. Tonsils present with no injection or exudate. Uvula midline, pink with no edema or lesions.

Neck:

• Trachea midline. No masses, lesions, scars, pulsations. Supple and non-tender to palpation. Thyroid non-tender to palpation. No masses or thyromegaly noted. 

Lymph nodes:

• No cervical, axillary or inguinal lymph nodes

Cardiac:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs or rubs. No S3 or S4. Radial pulses 2+. 

Lungs:

• Symmetrical, no deformities, no trauma. Respirations even and unlabored, no use of accessory muscles, stridor or wheezing noted. Non-tender to palpation throughout. Clear to auscultation bilaterally. No adventitious sounds.

Abdomen:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. No distention, soft, without tenderness. No rebound tenderness, guarding, or rigidity. No hepatosplenomegaly to palpation. No masses appreciated.

Neurologic:

• Patient is awake and alert. 

Differential Diagnosis:

• Acute lymphoblastic leukemia
  • ALL is the most common childhood malignancy. Hematologic symptoms (such as bruising) and musculoskeletal pain are two of the most common presenting symptoms of ALL. Bruising is obviously present in this case, and the knee pain which the pt mentioned may count as musculoskeletal pain. Although the pt denies any systemic symptoms (fever), and on exam no hepatomegaly or lymphadenopathy was noted, this does not rule out this diagnosis as early ALL may not have systemic symptoms yet.  
• ITP
  • ITP typically presents with sudden appearance of petechiae and/or bruising in an otherwise healthy appearing child. The lack of systemic symptoms in this case is consistent with the typical presentation of ITP. ITP commonly occurs after a vaccination or infection, though there are often cases of idiopathic ITP.  
• Von Willebrand disease
  • Von Willebrand disease is a hereditary condition that is more common in females than males. Due to the fact that there is no known family history of this disorder, this diagnosis is less likely. VWD typically presents with bruising, mucocutaneous bleeding and heavy menstruation. This pt only has one of those symptoms. However, the fact that she had a similar experience at age 8 makes us think that this is undiagnosed VWD. It is very common for VWD to go undiagnosed for many years.
• Accidental trauma
  • The pt claims to fall and bump into things a lot. If the bruising was limited to her lower extremities it would be more acceptable as an explanation, but because it involves her arms as well it is less believable. This would be a diagnosis of exclusion. 

Assessment:

• 15 year old female with no PMHx presents with diffuse bruising over bilateral arms and legs x1 week. Vital signs are within normal limits and on exam dozens of yellow/green bruises were seen. No other notable findings on exam. Presentation may be due to accidental trauma, however is concerning for ALL and must be worked up.

Plan:

• Obtain labs
  • CBC, PT, PTT, LFTs, CMP
  • Peripheral blood smear
  • Von Willebrand factor antigen and activity
• Education regarding importance of the above tests
• Education regarding potential diagnoses and offer support
• Continue plan based on results and final diagnosis
  • ALL→ referral to heme/onc
  • ITP→ steroids, IVIG
  • VWD→ DDAVP, avoid NSAIDs
  • Accidental trauma→ vision testing, if bruising persists consider non-accidental trauma