CLIPP case 5. 16yo girl visit (fatigue, bleeding disorder, puberty)

Question 1

16yo girl presents with fatigue and “not being herself”

Answer 1

DDx:

• Hypothyroidism
• Infectious mononucleosis (EBV)
• IDA from menses or bleeding disorder
• Depression (LESS likely than adults to have early morning awakening and difficulty falling asleep)
• Adjustment to stressor
• Anorexia or bulimia
• Substance use

Question 2

Anorexia findings

Answer 2

Wt loss -> Amenorrhea -> Bradycardia -> electrolyte imbalances (alb, gluc, Na, Ca, Mg) -> arrhythmia -> circulatory collapse -> death

Question 3

HEEADSSS assessment

Answer 3

Home, Eating/excercise, Education/employment, Activities/relationships, Drugs/cigs/etoh, Sex, Suicide/depression, Safety, Spirituality

Question 4

Girls puberty

Answer 4

8-13yo

Breasts -> pubes -> growth (12) -> period -> full height (15)

Question 5

Boys puberty

Answer 5

10-15yo

testicles -> pubes -> penile growth -> ejaculations -> growth spurt (14) -> adult height (17)

Question 6

Constitutional short stature

Answer 6

Late bloomer. Will attain normal height, just later than peers. Due to late puberty.

Question 7

Lab tests for bleeding disorder

Answer 7

• CBC with platelets, reticulocyte count, RBC indices, smear
• PT (extrinsic) and PTT (intrinsic)
• Platelet function test (replaced the bleeding time)
• Factor VIII activity
• von Willebrand factor antigen and activity (also known as Ristocetin cofactor)

Question 8

vWF disease

Answer 8

• 1% population, most common inherited bleeding disorder, usually AD inheritance. *Symptoms: ecchymoses, epistaxis, menorrhagia, bleeding post-tonsillectomy and dental extractions, gingival bleeds
• Prolonged platelet function or bleeding time. aPTT may be normal.
• Check vWF ag, platelet function analysis, factor VIII levels
• Tx: DDAVP, possibly plasma vWF, tx menorrhagia with IUD or combined OCPs