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Thomas - 5 y/o - Coggle Diagram
Thomas - 5 y/o
Presenting Complaint
Unexplained nose bleeds
Bleeding
What pathways are involved in bleeding?
Initial thoughts: Heat e.g., rural environment, inland, high temperatures in physical environment, home environment e.g., trauma, young kids get blood noses, play "rough" on the playground, potential bullying.
Bruising on chest and upper arms
Unusual surfaces for bruises
History
Medical hx
Bruising is recent
Uncomplicated birth
Environmental vs Biological
Biological
Issues with coagulation pathway
Can the platelets plug but the thrombin/fibrin not create the net to effectively stop the bleeding?
Issues with platelet formation
Is there a problem with hematopoesis or the megakaryocytes?
Bleeding disorders spontaneous (noting no family hx)
Environmental
Trauma
Blowing nose too hard, picking nose
Physical abuse at school e.g., bullying
Heat and physical environment leading to nose bleeds
Carcinogens vs mutagens
Carcinogens:
Agents that promote or facilitate cancer development
Benzene; benzol such as gasoline and cigarette smoke
Asbestos
Pesticides
Mutagens
: Mutagens are agents that increase the frequency of mutations in DNA
Heat, UV (c.f., also a carcinogen), X-rays, radiation
Nutritional deficiencies due to financial difficulties leading to bleeding gums e.g., vitamin C and skirvy
Bleeding from gums
Family Hx
No family hx of bleeding disorders
Social Hx
No marital discord or abuse
Ruled out hypothesis of direct trauma from family
Rural family
Examination
Appears happy and alert, no signs are trauma, obstruction or infection
Helped rule out hypothesis of family trauma / bullying
Appears a little pale
Helped rule in nutritional deficiencies / biological cause of bleeding and bruising.
Nail beds are pink
Bleeding: No evidence of recent nose bleeding and gums are tender and examination triggers further bleeding.
Normal: Chest on auscultation, no hepatomegaly or splenomegaly, abdomen non-palpable and no lymphadenopathy.
Investigations
Normal erythrocytes, normal neutrophil and a normal lymphocyte.
Two leukaemic lymphoblasts are present
Blood Count:
mild normochromic anaemia, mildly elevated total white cells, and a moderately reduced platelet count: 50,000 per mL (RR 150,000-400,000).
Bone marrow aspiration and lumbar puncture of CSF performed.
Extensive bruising on legs and small bruises on face
Acute Lymphoblastic leukaemia (ALL)
