40yr female with severe thrombocytopenia and drop of HB

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I am Nomika. Alli (Roll no 179) of 8th Sem MBBS

A 40yr old female , daily wage laborer by occupation, R/O Peddideviripelli came to the OPD on 1st September 2023 with complaints of fever since 4 days, abdominal pain (epigastric and left hypochondriac) since 1 day , shortness of breath since 1 day.

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 1 week back and then developed fever, high grade a/o chills, intermittent in nature (evening raise ) since 4 days which relieved on taking medication(paracetamol). No diurnal variation.

Generalized weakness since 3 days

epigastric pain and left hypochondriac region pain since a day which is non radiating, spasmodic type of pain .

Shortness of breath since 1 day , insidious in onset, no orthopnea, no PND

No H/O vomitings, loose stools, pain abdomen, giddiness.

Story from 28th August 2023:

This 40 yr old female was apparently asymptomatic one week back and developed high grade fever, intermittent a/o chills and has undergone few blood tests which shown presence of Salmonella typhi + (diagnosed as Enteric fever @ typhoid)

She was admitted in a local hospital and took few medications via I.V. for 3 days (antibiotics and few unknown??) Later she was discharged and she developed Shortness of breath, insidious in onset (no orthopnea, no PND) and pain in epigastric region and left hypochondriac region which is non radiating, spasmodic type of pain. 

She came to KIMS Nkp on 1st September 2023 and got admitted. She was diagnosed with DENGUE (NS1 antigen positive) with severe thrombocytopenia, bi-cytopenia, neutropenia???

Her daily routine is waking up at 6: 00 am, breakfast (rice and curry) at 8:00 am and leave for work. She used to have her lunch as rice and curry  at 2: 00 pm . She returns to home by 6:00pm. She usually haves her dinner as rice with curry  at 9:00pm and goes to bed by 10:00 pm.

The patient used to lead her life normally before this week.

PAST HISTORY:

N/K/C/O DM, HTN, TB, Asthma, CAD, CVD, Epilepsy,..

H/O Enteric fever(similar complaints) 1 yr ago

SURGICAL HISTORY:

Tubectomy 18 yrs back

FAMILY HISTORY: Not significant

PERSONAL HISTORY:

Married (widow)

Daily wage laborer

Diet: mixed (nonveg once in a month)

Appetite: normal

Bowel & bladder movements: regular

Sleep: adequate, not disturbed

Addictions: none

Allergies: no known

MENSTRUAL HISTORY:

Age of menarche: 13 yrs

LMP: Aug 15th 2023

3 / 30 day cycle (no menorrhagia)

OBSTETRIC HISTORY:  G1P1L1

First preg.: FTNVD Male 

25 yrs alive and healthy

PHYSICAL EXAMINATION:

GENERAL:

Patient is conscious , not coherent and cooperative to time place and person.

Ht: 155cm         Wt: 65kg

Pallor: mild

Icterus: no

Clubbing: no

Cyanosis: no

Lymphadenopathy: no

Edema: no

Vitals: BP: 110/70mmHg

Temp: 98.8F

PR: 120 bpm

RR: 18 cpm

SpO2: 98%

GRBS: 144 mg%

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard

no thrills

no murmurs

RS: no dyspnoea

no wheeze

central position of trachea

normal vesicular breath sounds +

ABDOMEN: 

tenderness in left hypochondrium

mild distension 

normal hernial orifices

no free fluid

no bruits

liver and spleen not palpable

bowel sounds heard

CNS: conscious

coherent speech

no neck stiffness

kernig's sign negative

cranial nerves, motor system , sensory system: intact, normal

Glasgow scale: E4V5M6 =15

INVESTIGATIONS: 

1-9-23

anti HCV:

Blood grouping:

RBS: increased

Blood urea:

CUE:

DENGUE NS1 antigen: +ve

HBsAg

Hemogram: low platelets

HIV:

LFT: raised SGOT, SGPT, ALP

S.creatinine

S. electrolytes

2D DOPPLER ECHO:

USG:

ECG:

2-9-23

HEMOGRAM:

S. electrolytes:

Hemogram

3-9-23

HEMOGRAM:

S.electrolytes:

Hemogram:

4-9-23

PERIPHERAL SMEAR:

OCCULT BLOOD: +ve

Hemogram: decreasing HB

Fever chart:

PROVISIONAL DIAGNOSIS:

DENGUE FEVER(NS1 +ve ) with Severe THROMBOCYTOPENIA

Bicytopenia?? Neutropenia??

BILATERAL MILD PLERAL EFFUSION

?? HB mystery??

MANAGEMENT:

DAY 1 (1/9/23)

IVF -NS, RL, DNS

INJ. PAN 40mg IV/BD

INJ. OPTINEURON 10mp in 10NS IV/OD

Strict I/O Charting

monitor vitals

Doxycycline 100mg IV/BD

DAY 2(2/9/23)

Plenty of oral fluids

INJ. NEOMOL 1gm/IV

Tab. DOLO 650mg PO/TID

INJ.DOXY 100mg/IV/BD

INJ.PAN 40mg / IV/ OD

IVF- NS,RL,DNS

INJ. ZOFER 4mg/IV/SOS

Tab. SPOROLAC  DS/PO/TID

Vital monitoring

W/F bleeding manifestations

DAY 3 (3/9/23)

Plenty of oral fluids

INJ. NEOMOL 1gm/IV

INJ.DOXY 100mg/IV/BD

INJ.PAN 40mg / IV/ OD

IVF- NS,RL

INJ. ZOFER 4mg/IV/SOS

Tab. SPOROLAC  DS/PO/TID

Vital monitoring

SYP ASCORYL D PO/TID

15ml ---15ml---15ml

DAY 4 (4-9-23)

Plenty of oral fluids

INJ. NEOMOL 1gm/IV

Tab. PCM 650mg PO/TID

INJ.DOXY 100mg/IV/BD

INJ.PAN 40mg / IV/ OD

IVF- NS,RL

INJ. ZOFER 4mg/IV/SOS

Tab. SPOROLAC  DS/PO/TID

Vital monitoring

Tab. REDOTIL 100mg PO BD