45 Y/ M with thrombocytopenia and rashes
45 yr old male ,farmer by occupation came to the casualty with the cheif complaints of
1.ECHYMOTIC RASH since 1week over
LEFT AND RIGHT THIGH , RIGHT FOREARM.
2. LEG PAINS since 2weeks.
HOPI:
Patient was apparently asymptomatic 2weeks back, then he developed bilateral leg pains ,not associated with fever, relieved on local rmp medication .
1week back he developed RASH in RIGHT THIGH FIRST, followed by LEFT THIGH AND RIGHT FOREARM, following which he went to hospital and incidentally found to have
THROMBOCYTOPENIA. and he also had h/o melena 4 days back .
NOT a k/c/o DM, HTN, asthma, TB, epilepsy.
No significant drug history.
No significant family history.
PERSONAL HISTORY:
He takes mixed diet
Sleep : adequate
Appetite- normal
Regular bowel and bladder movements.
TAKES REGULAR ALCOHOL.
O/E:
pt is c/c/c.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.
No malnutrition.
No dehydration.
VITALS:
Afebrile temperature
PR: 80bpm.
BP: 140/ 110 MMHG
RR:18CPM
SPO2: 98%
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
CLINICAL IMAGES :
Pt is HIV reactive
Provisional diagnosis :
Thrombocytopenia under evaluation
INVESTIGATIONS :
ON 1/11/21
S creat 0.8
S.electrolytes :
Na 137
K 3.7
Cl 101
Uric acid serum 3.6
Hbsag : non reactive
HCV : non reactive
HIV : REACTIVE
On 2/11/21 :
Direct coombs : negative
On 3/11/21
One SDP transfusion at night
On 4/11/21
SOAP NOTES :
DAY 1
2/11/21
S: No Fever spike
No any complaints
O : Pt is conscious ,coherent, cooperative
O/E :
PR 100 bpm
BP 140/100 mmHg
RR 18 cpm
Temp 98.6 F
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A : Thrombocytopenia secondary to ? Viral
HIV +
Echymotic patches over thighs and forearm
P :
Tab PCM 650 mg PO/ sos
IVF - NS , RL @ 50ML/HR
Watch for bleeding manifestations
Plan SDP transfusion
MONITER vitals and inform sos
INJ neomol 1 gm/ IV infusion of temp > 101 F
INJ Pan 40 mg /iv / od
INJ optineurin 1 AMP in 100 ml NS / iv / od
SOAP NOTES
DAY 2
3/11/21
S : No any complaints
O : Pt is conscious ,coherent, cooperative
O/E :
PR 90 bpm
BP 130/100 mmHg
RR 18 cpm
Temp 98.6 F
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A : Thrombocytopenia secondary to ? Viral
HIV +
Echymotic patches over thighs and forearm
P :
Tab PCM 650 mg PO/ sos
IVF - NS , RL @ 50ML/HR
Watch for bleeding manifestations
MONITER vitals and inform sos
INJ neomol 1 gm/ IV infusion of temp > 101 F
INJ Pan 40 mg /iv / od
INJ optineurin 1 AMP in 100 ml NS / iv / od
SOAP NOTES :
DAY 3
4/11/21
S : No any complaints
O : Pt is conscious ,coherent, cooperative
O/E :
PR 85 bpm
BP 130/90 mmHg
RR 18 cpm
Temp 97.8 F
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A : Thrombocytopenia secondary to ? Viral
HIV +
Echymotic patches over thighs and forearm
P :
1 SDP transfusion yesterday
as PLT count were 5,000
Tab PCM 650 mg PO/ sos
IVF - NS , RL @ 50ML/HR
Watch for bleeding manifestations
MONITER vitals and inform sos
INJ neomol 1 gm/ IV infusion of temp > 101 F
INJ Pan 40 mg /iv / od
INJ optineurin 1 AMP in 100 ml NS / iv / od
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