Anemia with thrombocytopenia
23 YR OLD WITH C/O BLEEDING FROM NOSE AND MOUTH SINCE 3 DAYS
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs
23 yR OLD FEMALE ,RESIDENT OF MOTHUKUR PRESENTED TO THE CASUALITY WITH
COMPLAINTS OF
BLEEDING FROM NOSE SINCE 3 DAYS
BLEEDING FROM MOUTH SINCE 1 DAY .
HISTORY OF PRESENT ILLNESS :
SHE WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK , THEN DEVELOPED FEVER WHICH IS SUDDEN IN ONSET along with rashes on abdomen, and limbs. After the fever has subsided ( .subsided by itself4 days later) she had episodes of bleeding from nose which is on and off for 3 days and bleeding from mouth since 1 day. .for which they visited to local hospital and was told to be anemic and decreased platelet count...and got reffered here..
PAST HISTORY:
NO SIMILAR COMPLAINTS IN THE PAST
NOT A K/C/O DM,HTN,ASTHMA ,EPILEPSY ,CVA,CAD
NO DRUG HISTORY
NO PREVIOUS SURGERIES
NO H/O PREVIOUS BLOOD TRANSFUSION
FAMILY HISTORY:
NOT SIGNIFICANT
PERSONAL HISTORY:
NORMAL APPETITE
MIXED DIET
BOWEL AND BLADDER MOVEMENTS ARE REGULAR
SHE CHEWED TOBACCO FOR THE PAST 4 YRS AND STOPPED SINCE2-3 months
SHE CONSUMES TODDY DAILY AND ALCOHOL( 6 months back) 2 TIMES A WEEK
NON SMOKER
NO KNOWN ALLERGIES
MENSTRUAL HISTORY:
AGE OF MENARCHE-12 yrs
HER CYCLES WERE REGULAR
DAYS OF BLEEDING 6-8 days since 2 yrs
PADS PER DAY- 2
CLOTS -no
PAIN -no
WHITE DISCHARGE -no
GENERAL EXAMINATION:
CONSCIOUS, COHERENT, COOPERATIVE
NOURISHMENT??(NOT MALNOURISHED)
PALLOR + NT
NO ICTERUS
NO CYANOSIS
NO CLUBBING
NO GENERALISED LYMPHADENOPATHY
NO PEDAL EDEMA
VITALS (on admission)
TEMP 101 DEGREES F
PR: 120PER MIN
RR: 24 PER MIN
BP :110/50 mmhg
SpO2 100%
GRBS 125 mg %
SYSTEMIC EXAMINATION:
CVS :
S1S2 HEARD
NO MURMURS HEARD
RESP:
NO DYSPNEA
NO WHEEZE
POSITION OF TRACHEA - CENTRAL
VESICULAR BREATH SOUNDS HEARD
NO ADVENTITIOUS SOUNDS
P/A:
SHAPE: SCHAPHOID
NON TENDER
NO PALAPABLE MASSES
HERNIAL ORIFICES - NORMAL
NO FREE FLUID IN THE ABDOMEN
LIVER NOT PALPABLE
SPLEEN -NOT PALPABLE
BOWEL SOUNDS HEARD.
CNS:
INTACT
PROVISIONAL DIAGNOSIS :severe anemia with thrombocytopenia secondary to infectious cause??
INVESTIGATIONS :
CBP (on 12/06/21)
PERIPHERAL SMEAR
BLOOD SUGAR
BT, CT
PTI/ INR
APTT
RFT
LFT
VIRAL MARKERS
CHEST X RAY
ECG
TREATMENT :
treatment given on admission : ( 12/ 06/21)
1)TAB RIBOFLAVIN 10mg po bd
2)TAB BPLEX FORTE PO BD
3) INJ PAN 40mg iv od
4) INJ TRANEXEMIC ACID 500mg iv sos
5)SYP MUCAINE GEL 10 ml po tid
6)TAB PCM 650 mg po tid
7) INJ N60MOL 1gm iv sos
PRBC 1 UNIT
SDP GIVEN
ON 13/ 06/ 21
Vitals:
BP 110/60 mm hg
PR 90bpm
CBP
Treatment on 13/06/21
1)TAB RIBOFLAVIN 10mg po bd
2) INJ PAN 40mg iv od
3) INJ TRANEXEMIC ACID 500mg iv sos
4)SYP MUCAINE GEL 10 ml po tid
5)TAB PCM 650 mg po sos
6) INJ N60MOL 1gm iv sos
7)INJ.VIT B12 IN 100 NS IV
8) INJ.ONDANSETRON 4mg
On 14/06/21
Vitals
BP 100/60mmhg
PR 84bpm
TREATMENT GIVEN:
1)TAB RIBOFLAVIN 10mg po bd
2) INJ PAN 40mg iv od
3) INJ TRANEXEMIC ACID 500mg iv sos
4)SYP MUCAINE GEL 10 ml po tid
5)TAB PCM 650 mg po sos
6) INJ N60MOL 1gm iv sos
7)INJ.VIT B12 IN 100 NS IV
8) INJ.ONDANSETRON 4mg
