18y/F.

A 18yr old unmarried girl ,came to the opd with cheif complaints of fever 5 days ago 

History of passage of blood clots per vagina yesterday 

History of black colored stools since yesterday

Patient was apparently asymptomatic 5 days back ,later she developed high grade continuous fever , associated with chills which lasted for 2 days  and got subsided with medication.Since yesterday she complains of passage of altered colored blood per vagina  with an episode of passage of blood clots yesterday ,associated with diffuse abdominal pain. She also complains of passage of black colored stools since yesterday 

No history of cold,cough, diarrhoea,nausea,vomitings

No history of burning micturition,white discharge 

Not a K/C/O HTN,DM,CVA,CAD,asthma,epilepsy ,thyroid 

Past history : 

No similar complaints in the past 

No history of any surgeries or blood transfusions in the past 

Menstrual history : 

Past  menstrual history - 

She attained menarche at the age of 13 yrs and has regular cycles for every 30 days  with flow lasting for 5 days.No history of any pain or clots 

Present menstrual history : 

History of passage of altered colored blood per vagina since yesterday, associated with diffuse abdominal pain and used 1 pad per day  and fever as mentioned above 

No complaints of abdominal pain for present,white discharge, burning micturition

History of usage of 

Tab.tranexamic acid 500 mg od 

Tab.regestrone 10 mg od 

As prescribed by outside physician .

 The patient is conscious,coherent and cooperative, moderately built and nourished

General examination : 

No signs of pallor,icterus ,clubbing,cyanosis, lymphadenopathy,edema

Vitals at the time of presentation: 

BP: 110/70 mmHg

PR: 80 bpm

Temp: 98.4 F 

SpO2 : 98% at RA

GRBS : 124

 

Systemic Examination : 

CVS: S1,S2 heard

RS: BAE+, NVBS, 

 CNS: No FND

 Provisional dignosis:  Viral Pyrexia with thrombocytopenia

 FEVER CHART : 

Referred to OBG I/v/o altered colored blood per vagina  with an episode of passage of blood clots

Investigations : 

6/9/21 : 

 ECG : 

Chest  X- Ray : 

USG : 

UPT : 

Hemogram on 6/9/21 : 

Hb - 12.9 

Tc - 7900

PLT : 68,000

N - 40 

L - 50 

M - 09

E - 01

B - 00

PCV :  37.1 

MCV : 86.5

MCH - 30.1 

MCHC - 34.8 

Hemogram on 7/8/21: 

 Hemogram on 8/9/21 : 

Urea : 10 

Creat : 0.7 

Tb - 0.77

Db - 0.20

AST - 124

ALT - 82 

TP - 6.1

Alb - 3.4 

A/G ratio - 1.3 

CUE : 

Alb - nil

Sugar - nil

Pus cells. - 2 to 3 

Epithelial cells - 2 to 4 

RBC casts - nil 

Serology : negative

Dengue : IgM positive 

NS1 negative 

IgG negative

Treatment given : 

7/9/21 : 

1. IVF : NS,RL, DNS @ 125ML)HR 

2. INJ. PAN 40 MG IV OD

3. Tab. Dolo 650 mg PO SOS

4. Tab. Tranexa 500 mg PO/BD 

On 8/9/21 : 

1. IVF : NS,RL, DNS @ 125ML)HR 

2. INJ. PAN 40 MG IV OD

3. Tab. Dolo 650 mg PO SOS

4. Tab. Tranexa 500 mg PO/BD 

5. W/H Bleeding manifestations

SOAP NOTES : 

7/8/21 : 

SUBJECTIVE : 

No fever spikes 

No c/o black coloured stools 

Passage of clots per vagina ( decreased)

Objective : 

Afebrile 

BP : 110/70 mm Hg

PR : 94 bpm

CVS : S1, S2 + 

RS : BAE +

P/A : Soft, non tender 

          BS + 

CNS : No FND

Assessment : 

Viral pyrexia with thrombocytopenia.( IgM positive)

Plan of care : 

1. IVF : NS,RL, DNS @ 125ML)HR 

2. INJ. PAN 40 MG IV OD

3. Tab. Dolo 650 mg PO SOS

4. Tab. Tranexa 500 mg PO/BD 

Soap notes : 

8/9/21 : 

SUBJECTIVE : 

No fever spikes 

Passage of clots per vagina (decreased)

No c/o black coloured stools

Objective : 

Afebrile 

BP : 110/60 mm Hg

PR : 84 bpm

CVS : S1, S2 + 

RS : BAE + 

P/A : Soft, non tender 

          BS + 

CNS : No FND

Assessment : 

Viral pyrexia with thrombocytopenia.( IgM postive)

Plan of care : 

1. IVF : NS,RL, DNS @ 125ML)HR 

2. INJ. PAN 40 MG IV OD

3. Tab. Dolo 650 mg PO SOS

4. Tab. Tranexa 500 mg PO/BD