Mrs Q, a 40 year old mother of three, presents to her GP with a 2 month history of intermittent bruising. She initially thought it was nothing to worry about when the bruising first appeared on her upper thigh, which cleared after a short while. One morning she noticed significant bruising covering her arms and legs. She can’t recall any injuries but, being a pre-school teacher, she is very active during the day picking up children.
However, when she woke up with bruised lips, Mrs Q decided to visit her GP. The following is a summary of his history taking and physical examination:
1. No medical history, except for colds and flu and two episodes of nose bleeds.
2. No previous surgical history.
3. No smoking or alcohol usage.
4. Regular, but heavy menstruation. (Currently menstruating)
1. Slightly pale gums and tongue, small pinpoint bleeds and bruises on lips.
2. Normal cardiac and respiratory examination.
3. Normal abdominal examination with no enlarged organs.
4. Normal vaginal examination, blood noted – menstruation.
5. No abnormalities found on breasts.
6. Significant areas of purplish bruising on arms and legs.
Small blood-red, round, dots on arms and lower legs. If pressed on, they do not disappear.
Side Room investigations:
1. Pulse rate 89 beats per minute, blood pressure within normal range
2. Urine testing: clear
3. Haemoglobin level (finger prick): 11 g/dL
The GP is very concerned with his findings and decides to do a blood test. The results concerned him even more. He noted a low number of platelets (cells in the blood that makes the blood clot). The GP decides to refer Mrs Q to a physician to exclude Idiopathic Thrombocytopenia (ITP) – a condition which results from very low platelet counts and may lead to significant bruising.
The physician phoned the GP a week later, confirming all his findings, but saying there is more to the diagnosis than just ITP. Her platelet count had returned to normal.
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