CARE STUDY: A CHILD WITH HEMOPHILIA
Brian Winston is an 18-month-old with hemophilia. He is seen in the emergency room
following a fall from a 2-foot-high wall at a shopping mall.
CHIEF CONCERN:
“He fell and his nose is bleeding and his knee is swelling.”
HISTORY OF CHIEF CONCERN:
Brian was diagnosed as having hemophilia at birth because of history of disease in
family. Mother has VIII factor replacement at home and is knowledgeable in how to
administer it. Today, she only applied a cold compress to nose and knee and brought
child directly to emergency room as this was closer than going home. Child's nose is still
bleeding after 20 minutes; knee has discolored to a purplish blue and is swollen to twice
the size of opposite knee. No loss of consciousness after injury.
FAMILY PROFILE:
Family intact. Father, age 24, works as a parole officer. Mother, age 23, is homemaker
while she is attending evening classes to become an accountant. Family lives in upstairs
apartment over father's parents. Finances are rated as “doing all right.”
PREGNANCY HISTORY:
Pregnancy planned following loss of first pregnancy because of incompetent cervix.
Sirodkar sutures placed at 14 weeks; removed at pregnancy term. Child born by vertex
vaginal birth; no excessive bruising noticed at birth. Apgars: “good.”
HISTORY OF PAST ILLNESSES:
Infant not circumcised at birth because of history of disease in family. Hospitalized at 6
months for bleeding on hand that would not stop after mother clipped fingernail too short.
Child fell at 9, 12, and 14 months while learning to walk; factor replacement
administered each time at home with no apparent long-term effect. No hospitalizations;
no other major illnesses or childhood communicable diseases
HISTORY OF FAMILY ILLNESSES:
Mother's brother, age 24, has hemophilia; attending college; has had little difficulty with
illness. An uncle of mother's died of disease of cerebral hemorrhage at age 12.
Paternal grandfather: left leg amputated for injury in World War II; ambulatory with
prosthesis. Maternal grandmother: alcoholism and liver and esophageal varices.
DAY HISTORY:
Nutrition: Child eats at table with parents; no special foods prepared for him.
Sleep: Sleeps 10 hours at night; 1-hour nap in afternoon.
Play/recreation: Child participates in preschool play group from church three afternoons
per week.
, Growth and Development: Child met infant developmental milestones: sat at 8 months;
walked at 14 months. Speaks many words; mother not certain he actually forms
noun-verb combinations yet.
REVIEW OF SYSTEMS:
Overall Health: good.
Eyes: Eyes crossed frequently at birth; were straight without therapy by 3 months; no eye
infections.
Ears: Hearing never formally tested but mother feels it is adequate. No ear infections.
PHYSICAL EXAMINATION:
General Appearance: Crying 18-month-old male with a bleeding nose and swollen,
discolored left knee.
Weight: 23.5 pounds (25th percentile). Height: 32 inches (50th percentile).
BP: 80/50.
Head: Normocephalic; posterior fontanelle closed; anterior fontanelle still palpable; Head
circumference: 47.5 cm (50th percentile).
Eyes: Red reflexes present bilaterally; child refused to follow light to test extraocular
muscles; eyes in straight alignment by Hirschberg test.
Ears: TMs: pink, landmarks prominent. Child responds to whispered word.
Nose: Midline septum; point in left nares actively bleeding; bleeding does not halt in
response to normal pressure.
Mouth and Throat: 18 teeth; no caries. Midline uvula; no erythema
Neck: Full range of motion; no palpable lymph nodes; midline trachea
Lungs: Clear to auscultation and percussion; no adventitious sounds; respiratory rate: 24
breaths per minute (crying)
Heart: Rate: 110 beats per minute; no murmurs
Abdomen: Bowel sounds heard in all four quadrants; no masses, not tender to touch.
Genitalia: Normal male; testes descended bilaterally; uncircumcised.
Extremities: Full range of motion in all but left knee; child has limited motion in knee
from pain and swelling; knee increased in size to twice that of opposite knee; has
discolored to purple and is warm to touch.
Neuro: Child is aware of surroundings; answers to name. Reflexes not tested to avoid
pressure near joints.
Brian is diagnosed as a child with hemophilia with active bleeding into his
right knee joint.
Brian Winston is an 18-month-old with hemophilia. He is seen in the emergency room
following a fall from a 2-foot-high wall at a shopping mall.
CHIEF CONCERN:
“He fell and his nose is bleeding and his knee is swelling.”
HISTORY OF CHIEF CONCERN:
Brian was diagnosed as having hemophilia at birth because of history of disease in
family. Mother has VIII factor replacement at home and is knowledgeable in how to
administer it. Today, she only applied a cold compress to nose and knee and brought
child directly to emergency room as this was closer than going home. Child's nose is still
bleeding after 20 minutes; knee has discolored to a purplish blue and is swollen to twice
the size of opposite knee. No loss of consciousness after injury.
FAMILY PROFILE:
Family intact. Father, age 24, works as a parole officer. Mother, age 23, is homemaker
while she is attending evening classes to become an accountant. Family lives in upstairs
apartment over father's parents. Finances are rated as “doing all right.”
PREGNANCY HISTORY:
Pregnancy planned following loss of first pregnancy because of incompetent cervix.
Sirodkar sutures placed at 14 weeks; removed at pregnancy term. Child born by vertex
vaginal birth; no excessive bruising noticed at birth. Apgars: “good.”
HISTORY OF PAST ILLNESSES:
Infant not circumcised at birth because of history of disease in family. Hospitalized at 6
months for bleeding on hand that would not stop after mother clipped fingernail too short.
Child fell at 9, 12, and 14 months while learning to walk; factor replacement
administered each time at home with no apparent long-term effect. No hospitalizations;
no other major illnesses or childhood communicable diseases
HISTORY OF FAMILY ILLNESSES:
Mother's brother, age 24, has hemophilia; attending college; has had little difficulty with
illness. An uncle of mother's died of disease of cerebral hemorrhage at age 12.
Paternal grandfather: left leg amputated for injury in World War II; ambulatory with
prosthesis. Maternal grandmother: alcoholism and liver and esophageal varices.
DAY HISTORY:
Nutrition: Child eats at table with parents; no special foods prepared for him.
Sleep: Sleeps 10 hours at night; 1-hour nap in afternoon.
Play/recreation: Child participates in preschool play group from church three afternoons
per week.
, Growth and Development: Child met infant developmental milestones: sat at 8 months;
walked at 14 months. Speaks many words; mother not certain he actually forms
noun-verb combinations yet.
REVIEW OF SYSTEMS:
Overall Health: good.
Eyes: Eyes crossed frequently at birth; were straight without therapy by 3 months; no eye
infections.
Ears: Hearing never formally tested but mother feels it is adequate. No ear infections.
PHYSICAL EXAMINATION:
General Appearance: Crying 18-month-old male with a bleeding nose and swollen,
discolored left knee.
Weight: 23.5 pounds (25th percentile). Height: 32 inches (50th percentile).
BP: 80/50.
Head: Normocephalic; posterior fontanelle closed; anterior fontanelle still palpable; Head
circumference: 47.5 cm (50th percentile).
Eyes: Red reflexes present bilaterally; child refused to follow light to test extraocular
muscles; eyes in straight alignment by Hirschberg test.
Ears: TMs: pink, landmarks prominent. Child responds to whispered word.
Nose: Midline septum; point in left nares actively bleeding; bleeding does not halt in
response to normal pressure.
Mouth and Throat: 18 teeth; no caries. Midline uvula; no erythema
Neck: Full range of motion; no palpable lymph nodes; midline trachea
Lungs: Clear to auscultation and percussion; no adventitious sounds; respiratory rate: 24
breaths per minute (crying)
Heart: Rate: 110 beats per minute; no murmurs
Abdomen: Bowel sounds heard in all four quadrants; no masses, not tender to touch.
Genitalia: Normal male; testes descended bilaterally; uncircumcised.
Extremities: Full range of motion in all but left knee; child has limited motion in knee
from pain and swelling; knee increased in size to twice that of opposite knee; has
discolored to purple and is warm to touch.
Neuro: Child is aware of surroundings; answers to name. Reflexes not tested to avoid
pressure near joints.
Brian is diagnosed as a child with hemophilia with active bleeding into his
right knee joint.
