Mdm. SH a 24year old Malay girl who is a known case of Chronic Idiopathic Thrombocytopenic Purpura (ITP) since childhood who currently presents with history of a 2 day high grade fever associated with coryzal symptoms, and an productive cough with whitish clear sputum. She experienced 3 episodes of gum bleeding, 1 episode of epixtaxis and had developed a rash over her limbs and torso within these 2 days. She had 2 similar presentation in January this year and October last year. Those times she was treated with a diagnosis of acute on chronic ITP, and was given T. Prednisolone 40mg BD in October and did not receive medications on discharge during her October stay. She has no history of prior transfusion, traditional medications, history of sick contact or travel, history of menstrual irregularities, or history of abdominal pain. She also denied history of anemia, muscle pain, joint swelling, or any retro-orbital pain. She also has had no dietary changes.
On Examination her vital signs revealed a temperature of 40 degrees Celsius, blood pressure of 120/80mmHg, Pulse rate of 74bpm regular, symmetrical and good volume. She appeared to be conscious, alert, and communicative. She looked ill (septic), was not cushingoid and had petichae's over all four limbs, echymosis of the hard palate. There was no muscle haematoma, haemarthroses, anemia, stigmata of chronic liver disease, telangectasia, or palpable lymph nodes. All systemic examinations were normal except reduced air entry over the right lung with ronchi predominantly on the lower lobe of the right lung.
Investigations done revealed
FBC - Hb - 11.4 g/dL, WCC - 6.6x10^9?L, Plt - 18 X10^9/L
BUSE - Urea - 2.9mmol/L, Sodium - 138mmol/L, Pottasium - 3.3mmol/L , Creatnine - 54mmol/L
CRP - 36.7mg/L
UFEME - Ketone 5+, Ereythrocyte 50, Red Blood Cells - 3-4hpf, Epithelial Cells - 1-2hpf
She was then treated with a diagnosis of Acute on Chronic ITP, there were no measures taken to culture or investigate her underlying infection, no Chest X-ray was done to look for lung disease, no Dengue immunoglobulin markers were taken, a Live function test was not done,
She was given,
- IV Platlet 4U together with IV Methylprednisolone 500mg OD x 3/7
- T. Prednisolone 60mg BD discharged with a monthly reduction of 5mg
- T. Calcium Lactate 600mg ON
- T. Paracetamol 1g QID
- T. Ranitidine 300mg OD
- T. Omeprazole 20mg OD
- IV Fluids maintainence at 4pints over 24hours
Her Platelet count post transfusion was 28, and she was allowed to be discharged after a 3 day still febrile with 38 degrees Celsius, still having a cough, still having the petichae's. If the patient were to ask "Whats wrong with me?" , "Why am I always getting sick in these past few months?", "Am I ok?"...... How will you answer, and what would be your approach to this patient if she happens to get admitted during your call?
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