Gestational Thrombocytopenia
A 26 YEAR FEMALE, G4P1L1A2 with 25 weeks 3 days GA with previous LSCS with ? Gestational Thrombocytopenia, ?ITP, ?APLA
This is an online E log book to discuss our patient's de-identified health data shared after taking 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 also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.
K.Lahari
Roll no. 61
CASE:
A 26 Year old Female, Housewife, G4 P1 L1 A2 with 25 weeks 3 days gestational age with previous LSCS.
Patient on regular checkup during pregnancy was found to have platelets 20,000 and was referred to our hospital.
HOPI:
T1- Spontaneous conception, h/o vomitings (subsided), no H/O Fever with rash, no H/O radiation exposure, white discharge, early Obs scan done
T2- Quickening present at 5th Month, TIFFA done at 7 weeks- normal
LMP- 6/04/2022
EDD- 13/1/2023
SEDD- 7/1/2023 (9 weeks, 3 days)
POG- 25 weeks + 3 days
PAST HISTORY:
No H/O DM, HTN, ASTHMA, , CAD, Epilepsy, Bleeding disorders
No H/O Drug Intake
PERSONAL HISTORY:
Diet - mixed
Appetite - Normal
Sleep - adequate
Bowel and bladder movements- Regular
No known allergies to drug and food
No addictions
Marital status - Married
MENSTRUAL HISTORY:
Menarche - 13years
3-5 Days/30 cycle
LMP- 6/04/2022
OBSTETRIC HISTORY :
Age at marriage- 18 Years
Age at first child birth- 20 Years
Gravida- 4
Para- 1
No. Of living children- 1
No. Of abortions- 2 at 6 weeks
GENERAL EXAMINATION:
After taking consent, the pateint was examined in a well lit room.
The patient is conscious, coherent, cooperative and we'll oriented to time, place and person.
She is thin built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Edema, dehydration.
Temperature - Afebrile
Pulse - 80bpm
Respiratory rate - 16cpm, regular
Blood pressure - 100/60 mmHg
SpO2 - 99% at room air.
INVESTIGATIONS:
1. HEMOGRAM
2. CUE
3. MALARIAL PARASITE
4.PROTHROMBIN TIME
5. APTT
6. SERUM ELECTROLYTES
7. LFT
8. BLOOD SUGAR- RANDOM
9. BLOOD UREA
10. SERUM CREATININE
11. ECG
12. USG
PROVISIONAL DIAGNOSIS:
A 26 YEAR FEMALE, G4P1L1A2 with 25 weeks 3 days GA with previous LSCS with ? Gestational Thrombocytopenia, ?ITP, ?APLA
TREATMENT:
1. 1 SDP TRANSFUSION
2. Daily Fetal heart, Fetal movements count monitoring
3. T. FERROUS ASCORBATE 100MG PO/BD
4. T. CALCIUM 1000MG PO/BD
5. T. ULTA MW 500MG PO/OD
6. T. MVT PO/OD
7. GRBS MONITORING
Comments
Post a Comment