50 year old male with vomitings and giddiness

A 26 YEAR FEMALE, G4P1L1A2 with 25 weeks 3 days GA with previous LSCS with ? Gestational Thrombocytopenia, ?ITP, ?APLA 

- 1/10/2022

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.

B Madhu kumar

ROLL NO. : 18

INTERN

I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, Clinical findings, investigations and come up with a diagnosis and treatment plan.

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:

No H/O Hematuria, Blood in stools, hematemesis, hemoptysis

• 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