A 30 years old female with ITP and dengue hemorrhagic fever



This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

A 30 years old female came to opd with chief complaints of bleeding from gums since yesterday morning with multiple reddish swelling in oral cavity
Multiple small swellings all over the body ( petechiae)  since yesterday evening
Increased menstrual bleeding since 10 days 
Fever since 1 day

On 14th sep 2021, she had a history of fever high grade associated with chills for 5 days 
H/o nausea and vomiting the contents being water and it was non projectile and non bilious
Also had generalized weakness for 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.

History of presenting illness
Patient was apparently asymptomatic 2 days ago and then she developed multiple reddish swelling in oral cavity
Gradually progressive
They bleed on touch
 On consumption of food? 
Not associated with pain 
No difficulty swallowing
No history of throat pain
Excessive salivation is present
Is it interfering speech? Yes

Multiple small swelling all over the body (petechiae) are present on upper limbs and on chest 
Blanching or not?

History of fever since yesterday morning not associated with chills and rigor and is of low grade 

Subconjunctival hemorrhage is present in the right eye 

History of blood in urine is present
No history of blood in stools, hemoptysis or hematemesis

Menstrual history
Age at menarche is 13 years
Regular cycles for every 28 days and flow is for 3 days
No of pads used is 2 per day 
No clots or dysmenorrhoea
Her last LMP was on 1st October and she had spotting on 11th October and no soakage of pad
She had history of 6 abortions in the past due to bleeding pv during pregnancy

Marital history:
Age at marriage 16 years in 1999
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.
Abortion 1:  in March 2001
After 1 and half years of marriage, she conceived spontaneous and in first trimester she developed bleeding PV and there was a spontaneous abortion at 2 and a half months

Abortion 2: 
After 6 months of 1st abortion , she conceived spontaneously and with in first trimester(around 10 weeks) ,she developed bleeding PV and there was a spontaneous abortion.

Abortion 3:
She conceived spontaneously 6 months after second abortion
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.

Abortion 4:
After 1-2 years of 3rd pregnancy , she was conceived again and spontaneous abortion with in 1st trimester at 3rd month

Abortion 5:
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 3rd months and was spontaneous

Abortion 6:  in July 2021
After 5th pregnancy , patient stopped visiting doctor and fed up with treatment and After 3 years she conceived spontaneously and there was a 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.

Past history
The patient was born on 1983 
All the milestones were achieved
Immunization done 

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.

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.

Not a known case of hypertension, diabetes, CAD, asthma, epilepsy, thyroid

Family history
Insignificant

General physical examination
Patient is conscious coherent and cooperative 
She was examined in a well lit room and with informed consent

Pallor is present
No icterus, cyanosis, clubbing, lymphadenopathy, edema

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

Systemic examination
CVS - s1 , s2 heard No murmurs
RS - trachea central, bilateral air entry present, Normal vesicular breath sounds present
No crepts
P/A soft , non tender and no organomegaly
CNS higher motor functions are intact
ENT examination
Oral cavity
Mouth opening is adequate
Hemorrhagic bleb on left side of buccal mucosa over inner aspect of Lowe lip is seen and along the gums and hard palate
Oropharynx:
Hemorrhagic bleb is present on soft palate on left side around uvula
Ear
Hemorrhagic bullae present over floor of EAC

Investigations:
USG abdomen
colour doppler 2D echo 
Hemogram
Bleeding and clotting time
Peripheral smear
APTT
Prothrombin time
Blood urea 
Serum creatinine
LFT
ECG


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

Treatment:
Inj Tranexa 500mg IV stat
IVF NS or RL @100 ml/hr
Inj Optineuron 1 amp IV in 100 ml NS/IV/OD
1 SDP transfusion stat 
Daily platelet monitoring
BP, PR, spo2 monitoring 2 hourly

On 13th Oct
Inj Tranexa 500mg IV BD
IVF NS or RL @100 ml/hr
Inj Optineuron 1 amp IV in 100 ml NS/IV/OD
Syrup mucain gel 10ml PO TID
2% betadine mouth gargles during early mornings
Tab. Primolut-N 5 mg PO TID
Inj. Tramadol 1amp in 100ml NS IV SOS
Daily platelet monitoring
BP, PR, spo2 monitoring 2 hourly

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