fever projr - unclassified 20/F 202241128

 unclassified - 20220946576

Diagnosis

IMMUNE (IDIOPATHIC) THROMBOCYTOPENIC PURPURA WITH SEVERE IRON DEFICIENCY ANEMIA ?SECONDARY TO BLOOD LOSS

S/P 3UNIT PRBC TRANSFUSION (29/09/22 , 01/10/22 , 5/10/22) + 3 UNIT SDP TRANSFUSION (30/09/22 , 02/10/22 , 04/10/22)

ACUTE INTRAPARENCHYMAL HEMORRHAGE6.5 X 3.5 X 3.8 CMS (TRXAPXCC) NOTED IN THE CEREBELLUM.

ACUTE INTRAVENTRICULAR HEMORRHAGE NOTED IN 3RD AND 4TH VENTRICLES.

DAY 1 OF INTERMENSTRUAL BLEEDING WITH MENORRHAGIA (MENOMETTORHAGIA)

Case History and Clinical Findings

19 YR OLD FEMALE PATIENT CAME TO CASULAITY WITH CHEIF COMPLAINT OF

FEVER SINCE 3 DAYS

SOB SINCE 2 DAYS

HOPI:-

Patient was apparently asymptomatic 1 month back she developed increased menstrual bleeding for 9 days @ 4-5 days not associated with clots and dysmenorrhea .patient have similar complaints in this cycle no clots no pain 2 -3 pads . fever since 3 days low grade intermittent not a/w chills and rigors not a/w cold and cough , burning micturation , loose stools relieved on taking medications no body pains

Sob insidious in onset non progressive grade 2 (mmrc) not a/ w postural variation (no orpthopnea , platypnea , pnd) not a/w syncope palpitations .

Chest pain increased with exertion relived at rest pt was taken to private hospital and was decteted to have (HB- 1.9 , TLC- 10,800 , PLT- 18000 , Pcv -8.1 , ESR-35) and was referred here for blood transfusion

NO H/O black stools, hematemesis, bleeding, no previous blood transfusion

PAST HISTORY:-

Not a k/c/o DM, HTN,ASTHMA, TB , CAD, epilepsy ,THYROID

FAMILY HISTORY:-

no significant family history

PERSONAL HISTORY:-

DIET- mixed

APPETITE- normal

BOWEL AND BLADDER- regular

SLEEP- adequate

GENERAL EXAMINATION:-

Pt is c/c/c

PALLOR - present

No icterus , cyanosis , clubbing , lymphadenopathy, edema

VITALS ON EXAMINATION

BP-110/80mmhg

PR-110 bpm

RR-26 cpm

P/A- soft non tender

Temp-99 f

SYSTEMIC EXAMINATION:-

CVS - S1 S2 + no murmurs

RS - BLAE + , NVBS

P/A - soft, non tender

CNS - NAD

COURSE IN THE HOSPITAL:

PATIENT WAS ADMITTED WITH ABOVE COMPLAINTS AND EVALUATED FOR THE SAME.1 UNIT PRBC &1 UNIT SDP TRANSFUSIONS WERE DONE ON THE DAY OF ADMISSION.INJ.IRON SUCROSE WAS STARTED AFTER DOSE CALCULATION AND ANOTHER PRBC TRANSFUSION WAS DONE ON THE FOLLOWING DAY.PATIENT IMPROVED SYMPTOMATICALLY AND ANOTHER 2 UNITS SDP TRANSFUSION WERE DONE ON 2 CONSECUTIVE DAYS IN V/O GUM BLLED+ORAL MUCOSAL BLEED.PATIENT WAS STARTED ON T.PREDNISOLONE 30MG/PO/OD IN V/O IMMUNE THROMBOCYTOPENIC PURPURA AND ON DAY-6 OF ADMISSION PATIENT STARTED MENSTRUATING FOR WHICH OBGN REFERRAL WAS DONE IN V/O MENORRHAGIA AND THEIR ADVISE FOLLOWED. ON THE SAME DAY6 AT AROUND 5PM PATIENT C/O SUDDEN ONSET HEADACHE,VOMITING F/B UNRESPONSIVENESS.CT BRAIN WAS DONE WHICH SHOWED 6.5 X 3.5 X 3.8 CMS (TRXAPXCC) ACUTE INTRAPARENCHYMAL HEMORRHAGE NOTED IN THE CEREBELLUM &INTRAVENTRICULAR HEMORRHAGE NOTED IN 3RD AND 4TH VENTRICLES.INJ.MANNITOL 20% 100 ML IV/STAT,INJ.TRANEXA 1GM IV/STAT WERE GIVEN.PATIENT WAS INTUBATED IN V/O LOW GCS WITH FALLING SPO2 AND CONNECTED TO MECHANICAL VENTILATOR. INJ.METHYLPREDNISOLONE 900MG IV/STAT OVER 30MIN WAS GIVEN. IN V/O SEVERE BLEEDING (MENORRHAGIA , ?GI BLEED) - HYPOTENTION (BP 70/40 MMHG) 1 UNIT PRBC TRANSFUSION WAS STARTED AND PLANNED FOR SDP TRANSFUSION ASAP.PATIENT CONDITION AND NEED FOR FURTHER MANAGEMENT AVAILABLE TREATMENT OPTIONS (IVIG , PLASMAPHERESIS AND OTHER SUPPORTIVE CARE) IN HOSPITAL STAY WITH GRAVE PROGNOSIS AND IMPENDING DEATH HAS BEEN EXPLAINED TO HER ATTENDERS IN THEIR OWN UNDERSTANDABLE LANGUAGE AND IS BEING REFERRED TO HIGHER CENTRE FOR FURTHER TREATMENT IN A STABLE CONDITION(GCS: E1 VT M1 , PR:150 BPM , BP: 100/60 MMHG , SPO2: 98% ON MV-ACMV-VC MODE WITH FIO2:60%) WITH ALL THE SUPPORTIVE MEASURES.

Investigation

29/09/22

USG ABDOMEN:

FINDINGS:SLIGHTLY ALTERED ECHOTEXTURE OF SPLEEN-NON SPECIFIC

IMPRESSION: MILD ASCITIS

29/09/22

ECG- NORMAL SINUS RHYTHM

30/09/22

2D ECHO:

>MODE TR(ECCENTRIC TR) WITH PAH, TRIVIAL AR/MR

>NO RWMA, NO ASCITIS

>GOOD LV SYSTOLIC FUNCTION

>NO DIASTOLIC DYSFUNCTION

>NO LV CLOTS

SERUM FERRITIN: 3.8

SERUM IRON:30

DCT: POSITIVE (2+)

HEMOGRAM:

30/9/22

HB:1.7

TLC:15000

PCV:6.4

RBC:0.96

PLT:10000

1/10/22

HB:4.6

TLC:10000

PCV:15.4

RBC:1.80

PLT:6000

1/10/22

HB:4.2

TLC:6700

PCV:14.6

RBC:1.65

PLT:4000

2/10/22

HB:6.1

TLC:12000

PCV:20.4

RBC:2.21

PLT:6000

3/10/22

HB:6.5

TLC:9700

PCV:22.8

RBC:2.39

PLT:6000

4/10/22

HB:7.9

TLC:10100

PCV:24.7

RBC:2.70

PLT:9000

5/10/22

HB:5.8

TLC:9100

PCV:19.1

RBC:2.0

PLT:3000

5/10/22

HB:4.0

TLC:13350

PCV:14.9

RBC:1.38

PLT:10000

5/10/22

CT BRAIN:

IMPRESSION:

>E/O 6.5 X 3.5 X 3.8 CMS (TRXAPXCC) ACUTE INTRAPARENCHYMAL HEMORRHAGE NOTED IN THE CEREBELLUM.

>E/O INTRAVENTRICULAR HEMORRHAGE NOTED IN 3RD AND 4TH VENTRICLES.

Treatment Given(Enter only Generic Name)

1) INJ. IRON SUCROSE (200 mg +100 ml NS ) IV OD ON ALTERNATE DAYS

2) 2 UNIT OF PRBC BLOOD TRANSFUSION DONE (29/09/22 , 01/10/22)

3) 3 UNITS OF SDP TRANSFUSION DONE (30/09/22 , 02/10/22 , 04/10/22)

4) TAB.WYSOLONE (PREDNISOLONE) 30 MG PO OD (1MG/KG/DAY) - STARTED ON 05/10/22

5) WATCH FOR BLEEDING MANIFESTATIONS

6) MONITOR VITALS

ON DAY6 (05/10/22) AT AROUND 5PM PATIENT C/O SUDDEN ONSET HEADACHE,VOMITING F/B UNRESPONSIVENESS.CT BRAIN WAS DONE WHICH SHOWED 6.5 X 3.5 X 3.8 CMS (TRXAPXCC) ACUTE INTRAPARENCHYMAL HEMORRHAGE NOTED IN THE CEREBELLUM &INTRAVENTRICULAR HEMORRHAGE NOTED IN 3RD AND 4TH VENTRICLES.

INJ.MANNITOL 20% 100 ML IV/STAT

INJ.TRANEXA 1GM IV/STAT

PATIENT WAS INTUBATED IN V/O LOW GCS WITH FALLING SPO2 AND CONNECTED TO MECHANICAL VENTILATOR

INJ.METHYLPREDNISOLONE 900MG IV/STAT OVER 30MIN

COURSE IN THE HOSPITAL:

PATIENT WAS ADMITTED WITH ABOVE COMPLAINTS AND EVALUATED FOR THE SAME.1 UNIT PRBC &1 UNIT SDP TRANSFUSIONS WERE DONE ON THE DAY OF ADMISSION.INJ.IRON SUCROSE WAS STARTED AFTER DOSE CALCULATION AND ANOTHER PRBC TRANSFUSION WAS DONE ON THE FOLLOWING DAY.PATIENT IMPROVED SYMPTOMATICALLY AND ANOTHER 2 UNITS SDP TRANSFUSION WERE DONE ON 2 CONSECUTIVE DAYS IN V/O GUM BLLED+ORAL MUCOSAL BLEED.PATIENT WAS STARTED ON T.PREDNISOLONE 30MG/PO/OD IN V/O IMMUNE THROMBOCYTOPENIC PURPURA AND ON DAY-6 OF ADMISSION PATIENT STARTED MENSTRUATING FOR WHICH OBGN REFERRAL WAS DONE IN V/O MENORRHAGIA AND THEIR ADVISE FOLLOWED. ON THE SAME DAY6 AT AROUND 5PM PATIENT C/O SUDDEN ONSET HEADACHE,VOMITING F/B UNRESPONSIVENESS.CT BRAIN WAS DONE WHICH SHOWED 6.5 X 3.5 X 3.8 CMS (TRXAPXCC) ACUTE INTRAPARENCHYMAL HEMORRHAGE NOTED IN THE CEREBELLUM &INTRAVENTRICULAR HEMORRHAGE NOTED IN 3RD AND 4TH VENTRICLES.INJ.MANNITOL 20% 100 ML IV/STAT,INJ.TRANEXA 1GM IV/STAT WERE GIVEN.PATIENT WAS INTUBATED IN V/O LOW GCS WITH FALLING SPO2 AND CONNECTED TO MECHANICAL VENTILATOR. INJ.METHYLPREDNISOLONE 900MG IV/STAT OVER 30MIN WAS GIVEN.IN V/O SEVERE BLEEDING (MENORRHAGIA , ?GI BLEED) - HYPOTENTION (BP 70/40 MMHG) 1 UNIT PRBC TRANSFUSION WAS STARTED AND PLANNED FOR SDP TRANSFUSION ASAP. PATIENT CONDITION AND NEED FOR FURTHER MANAGEMENT AVAILABLE TREATMENT OPTIONS (IVIG , PLASMAPHERESIS AND OTHER SUPPORTIVE CARE) IN HOSPITAL STAY WITH GRAVE PROGNOSIS AND IMPENDING DEATH HAS BEEN EXPLAINED TO HER ATTENDERS IN THEIR OWN UNDERSTANDABLE LANGUAGE AND IS BEING REFERRED TO HIGHER CENTRE FOR FURTHER TREATMENT IN A STABLE CONDITION (GCS: E1 VT M1 , PR:150 BPM , BP: 100/60 MMHG , SPO2: 98% ON MV-ACMV-VC MODE WITH FIO2:60%) WITH ALL THE SUPPORTIVE MEASURES.