General Medicine Case Presentation

  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:

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