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pillars 12-2 oral

Max Fima is a 3 y/o boy without significant past medical history who presents to the PACU with abnormally heavy bleeding post/op right inguinal hernia repair at the inguinal incision site.

POSITIVE FINDINGS : The bleeding occurred about 1 hr after the uncomplicated repair procedure. according to his mother, max has a hx of frequent development of large bruises on occasions such as head bumps due to falls and immunizations along w/ recurring nose bleeds. Other than that…

NEGATIVE FINDINGS: his mother denied any hx of immediate-onset bleeding whenever he got cuts or any previous significant bleeding since birth.

PHYSICAL EXAM : His PE was significant for:

• SKIN: 4 cm right inguinal incision intact but slowly oozing blood; two resolving ecchymoses - one over left lower leg and another over right forearm; no petechiae or purpura; no jaundice
• MOUTH: no mucosal bleeding or petechiae noted, oropharynx is clear, mucous membranes moist

In summary, the pt is 3 y/o boy w/ no significant PMH now post-op day #0 s/p elective right inguinal hernia repair that is experiencing a slow hemorrhage post-op. His PE findings notable for the presence of ecchymoses w/o the presence of petechiae or mucosal bleeding, along w/ his frequent bruising and recurrent epistaxis is suggestive of hemophilia A. The presentation of abnormal bleeding post-op in a 3 y/o is suggestive of a heritable condition. Since his mother denies any previous occurrence of significant bleeding, max’s lower clinical severity appears to be a mild form of hemophilia A.

PLAN:

1. Admit to pediatric ICU; monitoring orders placed for frequent surgical incision assessments and measurement of vital signs

2. Pressure dressing applied to surgical site to assist in hemostasis

3. Strict bedrest with head of bed flat (Max cannot get out of bed or sit upright, to assist in hemostasis)

4. STAT lab studies: CBC, prothrombin time (PT), activated partial thromboplastin time (aPTT)

5. Pediatric hematology-oncology consult