Question

Case 16: 5M presents to the peds office with his mom because of continued oozing 2 days after a tooth extraction. The boy is well-developed and hemodynamically stable. He has no known medical problems, but his maternal uncle has hemophilia.

1. Emergency orders
2. Physical Exam
3. Diagnostic tests
4. Therapy
5. Location
6. Final order
7. Dx

Answer 1

1. Emergency orders:

- Administer immediate pressure to the site of oozing to control bleeding

- Establish intravenous access for possible fluid resuscitation or medication administration if necessary

- Notify the dentist or oral surgeon who performed the tooth extraction

2. Physical Exam:

- Assess vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation

- Conduct a comprehensive examination of the oral cavity, paying particular attention to the extraction site for signs of active bleeding or infection

- Perform a general physical exam to evaluate overall health and detect any additional abnormalities

3. Diagnostic tests:

- Complete blood count (CBC) with platelet count to evaluate for any underlying bleeding disorders or thrombocytopenia

- Coagulation studies including prothrombin time (PT pain associated with the extraction and any additional procedures as required

5. Location:

- The patient should be managed in the pediatric office initially, with close communication and coordination with the dentist or oral surgeon who performed the tooth extraction

- Depending on the severity of the bleeding and the patient's overall condition, transfer to a higher level of care, such as a hospital, may be necessary

6. Final order:

- When appropriate, establish a referral to a pediatric hematologist or a dentist/oral surgeon specializing in oral surgery and pediatric dental care for further evaluation and management of the patient's bleeding concerns

7. Diagnosis (Dx):

- Potential diagnoses may include:

- Post-extraction bleeding: Occurs commonly after dental extractions, often due to incomplete clot formation or dislodged clots

- Von Willebrand disease: A hereditary bleeding disorder characterized by deficiencies or dysfunction of von Willebrand factor, a protein critical for normal blood clotting

- Other coagulation disorders: Hemophilia or other clotting factor deficiencies, especially considering a positive family history of hemophilia in the maternal uncle.

Answer 2

In this case, the patient presents with continued oozing after a tooth extraction. Given the family history of hemophilia, it is crucial to consider bleeding disorders as a possible cause. The patient should receive supportive care and diagnostic tests such as complete blood count and coagulation profile to evaluate for bleeding disorders. Therapy may include administering clotting factor concentrates or platelet transfusion.

Step-by-step explanation:

In this case, the patient presents with continued oozing after a tooth extraction. Given the family history of hemophilia, it is crucial to consider bleeding disorders as a possible cause.

Evidence-based response:

1. Emergency orders: Provide supportive care and closely monitor the patient for any signs of worsening bleeding. Consider transferring to a higher level of care if necessary.
2. Physical Exam: Assess the site of tooth extraction for any signs of ongoing bleeding or hematoma formation. Check for any other signs of bleeding or bruising.
3. Diagnostic tests: Perform a complete blood count, coagulation profile, and factor VIII activity level to evaluate for any bleeding disorders, including hemophilia.
4. Therapy: Depending on the severity of the bleeding and the underlying cause, therapy may include administering clotting factor concentrates, platelet transfusion, or other appropriate interventions.
5. Location: Continue management in the pediatric office or transfer to a specialized center if necessary.
6. Final order: Close monitoring for signs of bleeding resolution and reevaluation as needed.
7. Dx: Possible differential diagnoses may include post-extraction bleeding caused by a clotting disorder such as hemophilia or other rare bleeding disorders.