Good Morning
CLINICAL CASE PRESENTATION
Presented by-
Dr. Md. Jubaer Uddin
Department of paediatrics, DCIMCH
PARTICULARS OF THE PATIENT:
Name: Fatima Islam
Age: 12 years
Sex: Female
Religion: Islam
Address: Adabor, Dhaka
Date of admission: 08/06/2023
Date of examination: 08/06/2023
CHIEF COMPLAINTS:
• Fever for 10 days.
• Multiple red spots on the skin all over the body for 2 days.
• Superficial spontaneous bleeding for 2 days.
HISTORY OF PRESENT ILLNESS:
According to the patient’s mother’s statement, she was reasonably
well 10 days back. Then she developed fever. Which was
intermittent in nature, not associated with chills & rigor, highest
recorded temperature was 102°F. She also complained of dry
cough present when fever persists. She also gave history of sore
throat and tonsillar enlargement. Then she took azithromycin and
paracetamol for fever and fever subsided with sweating.
Then after 5 days fever and sore throat again reappeared. Fever was
intermittent in nature. She also complained of vomiting for 1time 5 days
back. Vomiting was non projectile in nature, mixed with blood and
undigested food material. Then she again took Napa extend( paracetamol)
and fever subsided after some days. She also complained multiple red spots
on skin all over the body for 2 days. Those were non-palpable, non-
blanchable, first noticed in lips, then in hands ,then legs and subsequently in
other parts of the body. There were multiple red spots in upper and lower in
limbs ,but few in abdomen and back also.
She also complained of bleeding from nose, gums &
vagina for 2 days. Nasal bleeding occurred for multiple
times, small in amount, red in colour at the time of nose
picking. She also noticed vaginal bleeding ,bright red in
colour, small in amount and also bleeding from gums .
On query she gave history of loss of appetite, weight loss
(4-5 kg over last 6 month), oral ulcer, palpitation,
weakness & generalized bodyache. She denied any
history of chest pain, breathlessness, joint pain,
hematuria, dysuria, burning micturation. Her bowel &
bladder habit is normal.
PAST MEDICAL HISTORY
According to patient’s mother’s statement she was
diagnosed as a case of mumps 7 years back &
treated conservatively. But no medical record was
found.
DRUG HISTORY
She took Zimax (Azithromycin 500 mg) & Napa Extend
(Paracetamol 665 mg).
No history of allergy to drugs.
SOCIO-ECONOMIC HISTORY :
She is from a middle income family & drinks
arsenic free water.
PERSONAL HISTORY :
She is non-smoker & non-alcoholic.
There is no significant travel history.
FAMILY HISTORY
There is no history of such illness in her family.
Her parents has no history of bleeding disorder.
Both her father & mother is hypertensive. Her
siblings are in good health.
MENSTRUAL HISTORY :
Her menstrual cycle is normal with regular cycle
and normal flow.
WHAT SHOULD BE THE
FOCUSED
EXAMINATION?
GENERAL EXAMINATION:
Appearance: ill-looking and oriented
Body build: Average
Decubitus: On-choice
Co-operation: Co-operative
Anemia: Mild
Jaundice: Absent
Cyanosis: absent
Clubbing: absent
Koilonychia: absent
Leukonychia : absent
Edema: absent
Dehydration: absent
Bony tenderness: absent
Lymph node: not palpable
Thyroid gland: not enlarged
Skin condition: diffuse non-palpable and non-blanchable
purpura over the skin
Pulse: 84 bpm
Blood pressure:100/60mmHg
Temperature: 98°F
Respiratory rate: 18breaths/min
SPO2: 97% in RA
Cannula in situ: left hand
Petechiae on lip
Petechiae on the lower
extremities
Sore throat
ALIMENTARY SYSTEM:
Lips: there are multiple bleeding spot on both lips
Oral cavity: there are multiple bleeding spots over the
palate
Abdominal examination:
Inspection: Purpura over the skin
Palpation:
On superficial palpation: Tenderness absent
Deep palpation: Tenderness absent
Liver – not palpable Spleen- not enlarged Kidneys- not
ballotable
Percussion: No evidence of ascites No shifting dullness
Auscultstion: Bowel sound present
CARDIOVASCULAR SYSTEM EXAMINATION:
Inspection: No visible cardiac impulse,no scar mark.
Palpation: Apex beat was located in the left 5th
intercostal space just medial to the midclavicular line,
normal in character. There was no palpable thrill or left
parasternal heave present.
Auscultation: 1st & 2nd heart sound is audible in all
four areas. No murmur
Examination of other system reveals no abnormality
WHAT MAY BE THE
PROVISIONAL
DIAGNOSIS??
IDIOPATHIC THROMBOCYTOPENIC
PURPURA (ITP)
WHAT WILL BE THE
DIFFERENTIAL
DIAGNOSIS?
Differential diagnosis:
Aplastic anemia
Leukemia
Henoch Schonlein Purpura
SLE
Thrombotic thrombocytopenic purpura
WHAT INVESTIGATION
SHOULD BE DONE??
CBC with ESR
CBC WITH PBF
Dengue AG NS1(ICT)
ANA
ALT(SGPT)
CMV-IgM
HSV 1 & 2-IgM
CBC WITH ESR ON 08/06/2023
Hb-11.7g/dl
ESR: 45mm in 1st hour
Eosinophil- 12%
Platelet- 6000/cumm
CBC WITH ESR ON 09/06/2023
Hb-12.5g/dl
ESR- 38 mm in 1st hour
Eosinophill-10%
Platelet- 10000/cumm
CBC ON 20/03/2023
Hb-11.0g/dl
WBC-20,000/cumm
ESR-32mm in 1st hour
Neutrophil-92%
Platelet-15,000/cumm
Dengue AG NS1(ICT) Negative
Dengue antibody IgG+IgM (ICT method) Negative
ANA-30.6AU/ml negative
ALT(SGPT) ALT-18 U/L negative
CMV -IgM Negative
HSV 1& 2-IgM Negative
WHAT WILL BE THE
CONFIRMATORY
DIAGNOSIS?
Acute ITP(Post Viral infection)
Management-
ORDER ON ADMISSION ON 18/03/2023@11PM:
Inf.Normal saline-I/V @10drops/min
Inj.Methylprednisolone sodium succinate 500mg-1 vial mixed with 1000cc
normal saline @20drops/min
Tab.Norethisterone 5mg-1+1+1
Cap.papaya250mg-1+1+1
Tab.esomeprazole-1+0+1
Cap.Tranexamic acid 500mg-1+1+1
Tab.vitamin C (250mg)-1+1+1
FRESH ORDER ON 19/03/
[email protected]:
Inf.Normal saline(1L)-I/V @10drops/min
Inj.Methylprednisolone sodium succinate 1G-1 vial mixed with 100cc
normal saline @30drops/min
Tab.Norethisterone 5mg-1+1+1
Cap.papaya250mg-1+1+1
Tab.esomeprazole-1+0+1(1/2 hour B/M)
Tab.vitamin C (250mg)-1+1+1
Cap.Tranexamic acid 500mg-1+1+1
HOSPITAL COURSE :
Patient’s condition is improving
after getting treatment.
Bleeding from nose, gums & vagina
is stopped.
Petechiae over lips & extremeties is
decreased.
