Chronic Knee Pain And Anemia - Basketball

Abstract

2031 HISTORY: A 13 year old, female middle school basketball player admitted with a five day history of diarrhea and fatigue. Reports about ten dark stools per day. Also reported emesis progressing to hematemesis about two days ago. Since onset of symptoms, patient lost approximately 12 pounds. She was admitted after concerns about marked pallor and lethargy consistent with impending shock. Hemoglobin was 6.9g/dL. Patient reported chronic bilateral knee and hip pain whilst playing basketball. The pain is described as aching just below knees. Had been evaluated by rheumatologist and was being treated with ibuprofen 400 – 800mg every four hours for an unspecified diagnosis. PHYSICAL EXAMINATION: Vitals: Weight 41.4kg, Height 66 in, Pulse 120, RR 24, Blood Pressure 127/75. Tanner Stage II. General: Lethargic, pale adolescent. No evidence of clubbing or signs of heart failure were noted. Examination of hip revealed good range of motion with no evidence of weakness or pain, both knees revealed tenderness, swelling and prominence of the tibial tuberosity. DIFFERENTIAL DIAGNOSIS: Weight loss, hematochezia, pallor and joint pain Gastrointestinal hemorrhage or bleeding secondary to gastritis Systemic Lupus Erythematosis NSAID gastritis Juvenile Rheumatoid arthritis Bilateral Knee Pain Apophyseal Avulsion fracture Idiopathic Adolescent Anterior Knee Pain Syndrome Proximal tibial stress fracture Osgood Schlatter's disease TEST AND RESULTS: Hemoglobin 6.9g/dL. Hemoccult positive. Ova, parasites, bacteria negative in stool, C. difficile negative, H. pylori negative. Meckel scan negative. Abdominal Xray consistent with mild ileus. Endoscopy and colonoscopy revealed chronic gastritis and colitis. Normal hip xrays, films of knees showed some evidence of fragmentation and microavulsions of tibial tuberosity. FINAL WORKING DIAGNOSIS: Acute Gastrointestinal bleed with impending shock due to treatment of bilateral Osgood Schlatter's disease with NSAIDs. TREATMENT AND OUTCOMES: Immediate resuscitation with blood products and fluid. Ensure hemodynamic stability. She required three units of packed red blood cells and subsequently did well and was able to venture into further diagnostic and treatment options. Nonsteroidal anti-inflammatory medication egflibuprofen in monitored doses of 10 to 15mg/kg evert six to eight hours. Ensuring proper use and caution about use on empty stomach. Consider use of Misoprostol. Use of knee pads to protect area. Hamstring and quadriceps flexibility exercises. Referral to Physical therapist. Activity modification. Rest. Return to sports once anemia and fatigue resolve and tolerable pain with activity.