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Peripheral blood smear
7%
2/28
Creatinine level and percutaneous kidney biopsy
0%
0/28
Prothrombin time/partial thromboplastin time
89%
25/28
24 hour urine collection for porphyrin levels
Rheumatoid factor
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This pediatric patient is presenting with hemarthrosis following relatively minor trauma. Platelet count and coagulation studies, including CBC (for platelet count), PT/INR, and PTT, should be obtained to rule out an underlying coagulopathy. There are numerous causes of hemarthrosis, including: trauma, bleeding disorders (hemophilia), neurologic deficits, arthritis, neoplasms, vascular damage, and recent joint arthroplasty. Pharmacologic anticoagulation may also predispose a patient to develop hemarthrosis; this is most commonly seen in patients with supratherapeutic levels of warfarin. Calmbach discusses the presence of hemarthrosis of the knee. In patients without an underlying coagulation defect or other disorder, major trauma often is the cause of this finding. Either an intra-articular fracture or ligamentous rupture (ACL) are the most common causes of hemarthrosis of the knee. Dunn reviews the prevention and management of hemarthrosis in hemophilia patients. Prophylactic coagulation factor replacement is the primary way to reduce and prevent hemarthrosis and joint damage in hemophilia. Additionally, arthroscopic synovectomy has been shown to reduce hypertrophic synovium and the resultant bleeding that afflicts these patients. Illustration A is an example of the appearance of hemarthrosis (right knee, left side of the photograph). Illustration B is a lateral radiograph of a knee with lipohemarthrosis secondary to a tibial plateau fracture; note the fluid level (arrow). Incorrect Answers: Answer 1: A peripheral blood smear is not included in the initial work-up of a patient with hemarthrosis after minor trauma. Answer 2: Creatinine and kidney biopsy would not be useful in narrowing the differential diagnosis for this patient and would be inappropriate to order at this stage. Answer 4: 24 hour urine collection for porphyrin levels would be useful in confirming the diagnosis of porphyria cutanea tarda. Answer 5: Rheumatoid factor is elevated in rheumatoid arthritis but would not be helpful in this patient's presentation.
4.4
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