Texila American University

Case Report Format

Student Name: Dr.Shahzad Ahmad

Program/Specialization: Family Medicine

Hospital/Clinic Name: Salabiakhat Centre

Year of Study: 3rd Semester 2016

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INSTRUCTIONS
 All the fields are mandatory.
 Each field carries mark.
 Type the details in the respective columns.

EVALUATION CRITERIA
CRITERIA MARKS PROGRAM CHAIR
MARKS
Title 5
Abstract and summary 10
History 15
Examination 15
Diagnosis / Differential diagnosis 5
Investigations and interventions 10
Treatment 10
Discussion 15
Learning points 5
References 5
Communication and presentation 5
TOTAL MARKS 100

PROGRAM CHAIR COMMENTS:

PC’s SCORE
IDIOPATHIC THROMBOCYTOPENIC PURPURA OUT OF 5
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ABSTRACT- PC’s SCORE
OUT OF 5

This case related to 5 years old child, came to us Salabiakhat health care center with
the parents complaining of child having multiple bruising from last 2 weeks that
was investigated and diagnosed child having ITP. Treatment was done with follow
up. Child was perfectly fine 3rd day.

HISTORY
PC’s SCORE
Name:Adnan Rashid
OUT OF 15
Age : 5

5 years old child name Adnan brought to our Salabiakhat family health care center by
his mother complaining of having multiple bruising from almost last 2 weeks.

PAST MEDICAL HISTORY

Tonsillectomy
Vaccination schedule is up to date

HISTORY OF PRESENT ILLNESS

5 years old male healthy child previously. Brought to us by his mother because of
sudden multiple bruising from last 2 weeks. Mostly on upper and lower limbs.

1: No fever /chills/weight loss/bone pain /joint pain/nose bleed/head ache / blurry

vision
2: repeated episodes of sore throat
3: previously healthy and no such kind of problem before

Surgical history : tonsillectomy

Medication :none
Allergies: none
Family history: none
Birth history: normal delivery , no complications
Social history: lives with parents , 2 brothers and sister
Immunization : up to date
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EXAMINATION
Vitals:

Temp: 38.2 c
HR: 90/m
RR: 30/m
Bp: 105/60
Weight: 25kg

GENERAL: active and talking

ENT: normal

HEAD &NECK: NAD

HEART: NORMAL
PC’s SCORE OUT
HEENT: No headache ,congestion or epistaxis OF 15

RESP: No cough /wheeze

CARDIAC: No chest pain /cyanosis/palpitation

ABDOMEN: No abdominal pain , diarrhea or constipation, soft,non-tender,no

organomegaly

GU: none

SKIN: multiple patches of bruising, purpura multiple around knee.

EXTREMITIES: no swelling/effusion , normal

NEURO: No weakness or seizure

DIAGNOSIS : IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) PC’s SCORE

OUT OF 5

DIFFERENTIAL DIAGNOSIS
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1: Pseudo thrombocytopenia

2: liver disease

3: myelodysplasia

4: infection or sepsis

5: Drug induce

6: acute leukemia

7: transfusion

INVESTIGATIONS / INTERVENTIONS

CBS: 6.7
12.9
34.6/7
P/S: decreased platelets. Normal morphology of RBC,WBC

FULL PROFILE
PC’s SCORE
CMP: 142/3.5/104/27/11/0.5
OUT OF 10
Uric acid:4
LDH,600
ESR :10
PS
PT:11.8
INR:1.1
PTT:27

TREATMENT PC’s SCORE OUT

OF 10
Stop the BRUFEN (NSAIDS) that the child was taking for sore throat and fever

Limited the child activities and playing. Normally children with milder ITP do not
require monitoring and treatment. Usually those children recover without treatment.
 Texila American University
Case Report Format
Given IV IG 1 g /Kg IV x1 and keep the child under observe for 2 day with restricted
activities and after 2 days child was stable. Lesion was gone and platelets increased in
amount by normal and advice the parents to visit again after 1 week for follow up
and CBC.

DICUSSION PC’s SCORE OUT

OF 15
Immune thrombocytopenic purpura (ITP) is a clinical syndrome in which a decreased
number of circulating platelets thrombocytopenia manifests as a bleeding tendency,
easy bruising (purpura), or extravasation of blood from capillaries into skin and
mucous membranes (petechiae). Although most cases of acute ITP, particularly in
children, are mild and self-limited, intracranial hemorrhage may occur when the
platelet count drops below 10 × 10 9/L (<10 × 103/µL); this occurs in 0.5-1% of
children, and half of these cases are fatal

Signs and Symptoms

ITP is a primary illness occurring in an otherwise healthy person. Signs of chronic

disease, infection, wasting, or poor nutrition indicate that the patient has another
illness. Splenomegaly excludes the diagnosis of ITP.An initial impression of the
severity of ITP is formed by examining the skin and mucous membranes, as follows:

Widespread petechiae and ecchymoses, oozing from a venipuncture site, gingival

bleeding, and hemorrhagic bullae indicate that the patient is at risk for a serious
bleeding complication .If the patient's blood pressure was taken recently, petechiae
may be observed under and distal to the area where the cuff was placed and inflated

Suction-type electrocardiograph (ECG) leads may induce petechiae

Petechiae over the ankles in ambulatory patients or on the back in bedridden ones
suggest mild thrombocytopenia and a relatively low risk for a serious bleeding
complication

LEARNING POINTS PC’sSCORE OUT

OF 5
ITP is one of the most common causes of symptomatic thrombocytopenia in children
Incidence 3-8 /100,000 children/ year .Usual age 2-10 yrs ,peak 2-5yr Slightly
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boys>girls

Sudden appearance of bruising and/or bleeding in an otherwise healthy child. In 60%,

there is a history of prior infection. An increased risk of ITP is associated with MMR
immunization. No systemic symptoms Presence of systemic symptoms like
feve,anorexia,joint pain, bone pain or weight loss usually points to other diagnosis
Drug induced(heparin,quinidine,sulfonamides) thrombocytopenia is uncommon in
kids

REFERENCES PC’sSCORE OUT

OF 5

1: Fogarty PF, Segal JB. The epidemiology of immune thrombocytopenic purpura.

Curr Opin Hematol. 2007 Sep. 14(5):515-9

2: Nilsson T, Norberg B. Thrombocytopenia and pseudothrombocytopenia: a clinical

and laboratory problem. Scand J Haematol. 1986 Oct. 37(4):341-6

3: Sandler SG, Tutuncuoglu SO. Immune thrombocytopenic purpura - current

management practices. Expert Opin Pharmacother. 2004 Dec. 5(12):2515-27

4: [Guideline] Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA.

The American Society of Hematology 2011 evidence-based practice guideline for
immune thrombocytopenia. Blood. 2011 Apr 21. 117(16):4190-207

5: Anderson D, Ali K, Blanchette V, et al. Guidelines on the use of intravenous

immune globulin for hematologic conditions. Transfus Med Rev. 2007 Apr. 21

COMMUNIC ATION AND PRESENTATION PC’s SCORE

OUT OF 5
On complete blood cell count, isolated thrombocytopenia is the hallmark of ITP.
Anemia and/or neutropenia may indicate other diseases. Findings on peripheral blood
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smear are as follows:

1:The morphology of red blood cells (RBCs) and leukocytes is normal

2:The morphology of platelets is typically normal, with varying numbers of large

platelets

3:If most of the platelets are large, approximating the diameter of red blood cells, or if
they lack granules or have an abnormal color, consider an inherited platelet disorder

Many children with acute ITP have an increased number of normal or atypical
lymphocytes on the peripheral smear, reflecting a recent viral illness.