A case of 30 years old female with thrombocytopenia secondary to ITP..?

This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box



A 30 years old female came to opd with c/o bleeding from gums since 1 day with multiple reddish swelling in oral cavity.Excess salivation since 1 day.Multiple small swellings all over the body (petechae) since 1 day.Excessive menstrual bleeding since 10 days.Fever since 1 day ,low grade, not associated with chills.

Past history :

On 14th sep 2021, she had a  h/0 of fever , high grade associated with chills since 5 days , 
H/o nausea and generalized weakness since 5 days.She was diagonised as viral pyrexia and thrombocytopenia with serocytosis.

She was treated with IV fluids and antipyretics 

Platelets on admission was 42000 and it gradually increased to 1.1 lakh in 2-3 days followed which she was discharged and advised to get platelet monitoring after one week. But she failed to get it done.

She had history of 6 abortions in the past due to bleeding pv during pregnancy

The patient was born on 1983 

She was normal up to 12 years of age , At the age of 12,  she developed swellings under the mandibular region B/L , roughly about 2x2 cm ( left side size more than right ) .which was rapidly increased in size in about 10 days associated with fever and 
She was operated with submental incision and swellings were removed.

She was normal up to 16 years of age , At 16 years of age she was married and she used to go to work with her husband ( Her husband is a tractor driver by occupation and also make bore wells in agriculture fields.
 *1st pregnancy:* 
After 6 months of marriage, she conceived and with in first trimester ,she developed bleeding PV and there is spontaneous abortion.

 *2nd pregnancy:*
After 6 months of 1st abortion , she conceived and with in first trimester(around 10 weeks) ,she developed bleeding PV and there is spontaneous abortion.

 *3rd pregnancy:*

She was very much careful this time and used to have regular follow ups with the treating doctor.Till 6 months of pregnancy, there are no complaints. At 6 months of pregnancy, according to patient , because of lifting heavy weights she had PPROM and IUD and the treating doctor induced labour for the expulsion of fetus.

 *19 years of age:* 

At 19 years of age patient developed swelling inside the throat with pus(??pustular tonsillitis) .The uncle of the patient took a beedi with fire and passed through her nose and touched the beedi with the swellings.According to the patient ,the swellings was reduced and till now there is no history of swelling inside the throat.

 *4th pregnancy:* 

After 1-2 years of 3rd pregnancy , she was conceived again and  spontaneous abortion with in 1st trimester.

 *5th pregnancy:* 

After loss of 4th pregnancy, patient went to infertility doctor?? Took treatment for infertility for around 2-3 years , then she was conceived and there was pregnancy loss with in 3 months.

 *6 th pregnancy* 

After 5th pregnancy , patient stopped visiting doctor and fed up with treatment and After 3 years she conceived and there is pregnancy loss with in 3 months.

From then patient didn't conceive and adopted a female child from her younger brother and taking care of the child.

No h/o hematuria, hemoptysis,hematemisis,melana.


Not a known case of TB,HTN,asthama,epilepsy,

Vitals on admission :
Temp 99F
PR 94 bpm
BP 100/60 mmhg
RR 18 cpm
Spo2 99% at RA
GRBS 127 mg/dl

O/E 
Patient c/c/c
CVS - s1 , s2 +.No murmurs
RS - trachea central NVBS +.No crepts
P/A soft , non tender.

Provisional diagnosis: thrombocytopenia secondary to ITP ? With viral pyrexia secondary to dengue ( NS1 positive 15 days back)

Investigations on day of admission:-.

Hb- 9.9mg/dl
Tlc- 6600
Neu-67
Pcv-30.7
Mcv-76.4
Mch-24.6
Platelets- 2000/cumm
Smear-
Platelets-Reduced on smear
Hemoparasites-No hemoparasites
Impression-
Normocytic normochromic anemia
With severe thrombocytopenia
No atypical cells seen.

Bt-2min 30secs
Ct-5min 30secs
Peripheral smear:
RBC:NORMOCYTIC NORMOCHROMIC ANEMIA
WBC: with in normal limits with neutrophils showing toxic granules
PLATELETS:Reduced on smear
IMP:Normocytic normochromic anemia with severe thrombocytopenia.No atypical cells seen

Aptt:  40 secs
Prothrombin time: 20 sec
INR: 1.4
Blood urea:25mg/dl
Serum creatinine:0.8mg/dl

LFT:
Total bilirubin:1.41mg/dl
Direct bil:0.4mg/dl
AST:21
ALT:10
ALP:193
TOTAL PROTEINS:7.1
ALBUMIN:3.72
A/G:1.1

Treatment given :-

Inj. Tranexa 500mg IV/BD
IV fluids - NS, RL @100ml/hour
Inj Optineuron 1 ampule in 100ml NS IV/OD
Syp. Mucaine gel 10ml PO/TID
2% betadine mouth gargles early morning
Tab.Primolut N 5mg PO/TID
1 unit sdp transfusion was done in view of low platelet count.

Day 3
33 YEARS /FEMALE..
Soap notes 

S:
DECREASED BLEEDING FROM  GUMS.
BLOOD IN URINE
O:
Pt c/c/c
Temp-98.4F
BP-110/70mmhg
PR-84 bpm
RR- 18 cpm
CVS- S1 S2 +. No murmur
RS- NVBS+. No crepts 
P/A- soft, non tender
CNS- NAD
PLATELET COUNT:- 
DATE;- 14/10/2021---10000
Na+--142
K+:- --4
Cl:--103
A:
THROMBOCYTOPENIA WITH BLEEDING MANIFESTATIONS SECONDARY TO ITP?? WITH K/C/O DENGUE NS1 POSITIVE (15 DAYS BACK).


P:
IVF - NS, RL,  @ 100 ml/hr 
INJ. TRANEXA 500MG/IV/BD
INJ.OPTINEURON 1AMP IN 100 ML NS IV/OD
SYP. MUCAINE GEL 10 ML /PO/TID
2% BETADINE MOUTH GARGLES( DURING EARLY MORNING)
TAB. PRIMOLUT-N 5MG /PO/TID
TAB. WYSOLONE 50 MG PO/OD
ZYTEE GEL FOR L/A
STRICT BP MONITORING 4TH HOURLY


Day 4
33 YEARS /FEMALE..
Soap notes 

S:
DECREASED BLEEDING FROM  GUMS.
Malena present.
O:
Pt c/c/c
Temp-98.4F
BP-100/70mmhg
PR-84 bpm
RR- 18 cpm
CVS- S1 S2 +. No murmur
RS- NVBS+. No crepts 
P/A- soft, non tender
CNS- NAD 

PLATELET COUNT:- Dropped from 10,000 to 6000cells/mm

Hemoglobin: Dropped from 9.9g/dl to 6.1g/dl

A:
THROMBOCYTOPENIA WITH BLEEDING MANIFESTATIONS SECONDARY TO ITP?? WITH K/C/O DENGUE NS1 POSITIVE (15 DAYS BACK).


P:
IVF - NS, RL,  @ 100 ml/hr 
INJ. TRANEXA 500MG/IV/BD
INJ.OPTINEURON 1AMP IN 100 ML NS IV/OD
SYP. MUCAINE GEL 10 ML /PO/TID
2% BETADINE MOUTH GARGLES( DURING EARLY MORNING)
TAB. PRIMOLUT-N 5MG /PO/TID
TAB. WYSOLONE 50 MG PO/OD
ZYTEE GEL FOR L/A
STRICT BP MONITORING 4TH HOURLY


Day 5
33 YEARS /FEMALE..
Soap notes 

S:
BLEEDING FROM oral cavity present.
No Malena today morning.
O:
Pt c/c/c
Temp-98.4F
BP-110/70mmhg
PR-86 bpm
RR- 18 cpm
CVS- S1 S2 +. No murmur
RS- NVBS+. No crepts 
P/A- soft, non tender
CNS- NAD 

A:
THROMBOCYTOPENIA WITH BLEEDING MANIFESTATIONS SECONDARY TO ITP?? WITH K/C/O DENGUE NS1 POSITIVE (15 DAYS BACK).


P:
IVF - NS, RL,  @ 100 ml/hr 
INJ. TRANEXA 500MG/IV/BD
INJ.OPTINEURON 1AMP IN 100 ML NS IV/OD
SYP. MUCAINE GEL 10 ML /PO/TID
2% BETADINE MOUTH GARGLES( DURING EARLY MORNING)
TAB. PRIMOLUT-N 5MG /PO/TID
TAB. WYSOLONE 50 MG PO/OD
INJ.METHYPRED 1gm iv/OD IN 100ml ns 
ZYTEE GEL FOR L/A
STRICT BP MONITORING 4TH HOURLY

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