A 28 YR OLD FEMALE WITH RASH OVER RT FOREARM

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Pt. came for follow up
PAST HISTORY:10/4/22
Complaints of:
Loss of appetite since 3 days
Vaginal discharge since 1month 
Rash over the forearm since 5 days

History of presenting illness:
Patient was apparently asymptomatic 3 days back then she developed Rash over the right forearm since 5 days which was sudden in onset .No h/o trauma to the forearm
Pt had vaginal white discharge since 1month
Not associated with foul smelling ,itching not relieved by medication.

H/o rash over RT knee joint 20 days back relieved on application of (zandu balm)
H/o HYPOTHYROID  
IN 2018 -During 1st pregnancy TAB.THYRONORM 25MCG for 6months 
In 2021- During 2nd pregnancy in 2nd month 
   TAB.THYRONORM 50MCG for 7months 
N/K/C/O HTN,DM,TB,CAD,ASTHMA

GENERAL EXAMINATION 

Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

HESS TEST:
      4-5 petichae seen
Rash over RT.forearm
 RASH OVER RT.FOREARM




VITALS

Temperature -98.2F

Pulse rate- 78bpm

Blood pressure-120/70mm hg

Respiratory rate -19cpm

GRBS -136 mg/dl 

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

Provisional Diagnosis:

?CHRONIC ITP

INVESTIGATIONS:






Previous admission-10/4/22
Platelet count-16,000
14/4/22-50,000
Present admission-27/4/22
Platelet count-18,000
28/4/22-20,000
29/4/22-22,000

TREATMENT:
1)Tab.WYSOLONE 10 PO/TID
2.)Tab.BECOSULES PO/OD
3)W/F Bleeding manifestations
4)BP/PR/TEMP MONITORING


28/4/22
SOAP NOTES (AMC)
S-  No fresh complaints
    No bleeding manifestations 

O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE. 
NO PALLOR ,ICTERUS ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.

VITALS-
TEMPERATURE - 98.4F 
PULSE RATE-78bpm , REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 110/ 70 mm hg
SPO2 - 98% AT RA

On 

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD


A -  ? CHRONC ITP



P - 
1)Tab.WYSOLONE 10 PO/TID
2.)Tab.BECOSULES PO/OD
3)W/F Bleeding manifestations
4)BP/PR/TEMP MONITORING



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