Age: 30.0
Sex: F
Vaccine: HPV9
Symptoms: Epistaxis, Erythema, Full blood count, Globulins increased, HIV test negative
Clinical narrative: Patient went to primary care physician on 6/28/19 at 12:20pm with large bruises and red dots on both legs to be examined. PCP ordered CMP, CBC, Protime-INR, Sedimentation Rate, APTT, and ANA Screen and advised patient to get labs done today, avoid aspirin, report any further symptoms, and stand by for lab results. Patient provided blood and urine for labs that day. On 6/29/19 at 3:55am, patient received a call from the physician on-call advising her that her lab results came back with a dangerously-low platelet count of 3 and that she should go to the ER immediately to get her CBC re-checked. At the ER, platelets count came back at 1 and the patient was admitted to the ER. Patient given dexamethasone, IVIG, platelet transfusion, and admitted to hospital room for continued observation. On 6/30/19, CBC at 5:05am showed platelet count of 23. Later that morning, dexamethasone was given to patient orally. CBC at 2:10pm showed platelet count of 46 and patient was discharged from hospital with a prescription for 3 more days of 40mg of dexamethasone. Patient had office visit with hematologist on 7/2/19. CBC showed platelet count of 165. Patient told to finish course of dexamethasone and watch for signs of bleeding. On 7/9/19, patient contacted Dr with symptoms of bleeding: blood when blowing nose, petechiae. Hematologist advised she could come in for a CBC a day earlier than scheduled. Patient went to office and CBC showed platelet count of 4. Hematologist on-call prescribed course of 20mg of prednisone (Take 4 tablets by mouth daily for 3 days, then 3 tablets by mouth daily for 3 days, then 2 tablets by mouth daily for 3 days, then 1 tablet by mouth daily continued.) On 7/10/19, CBC showed platelet count of 8. On 7/12/19, CBC showed platelet count of 5, so Dr decided prednisone wasn't working and switched back to 4 day course of 40mg of dexamethasone, as well as ordered IVIG and platelets for the next day. On 7/13/19, CBC showed platelet count of 3 and patient received IVIG and platelets. On 7/18/19, CBC showed platelet count of 149. Dr advised that IVIG would not be an option soon because of a national shortage. While dexamethasone seems to work, it is only a short-term measure and long-term use should be avoided. Dr put in for insurance approval of rituximab and advised would schedule the infusions once approved. Rituximab was approved by insurance and the first infusion was scheduled for 7/21/19. On 7/21/19, patient came in for 1st infusion of rituximab. CBC showed platelet count of 3, so the hematologist on-call made the decision to postpone ritixumab and instead do a half-dose of IVIG and 1 unit of platelets. Patient received half-dose of IVIG and 1 unit of platelets. On 7/22/19, patient contact Dr about heartburn and Dr advised she should take over-the-counter omeprazole for stress-induced heartburn. Patient began 14 day course of omeprazole on 7/23/19. On 7/24/19, CBC showed platelet count of 8, so hematologist had patient start another 4 day course of 40mg of dexamethasone and ordered WinRho before the 1st infusion of rituximab. On 7/25/19, CBC showed platelet count of 42 and patient received WinRho with no major side effects. On 7/26/19, CBC showed platelet count of 104 and patient received 1st rituximab infusion with no major side effects. On 7/31/19, CBC showed platelet count of 26. On 8/2/19, CBC showed platelet count of 21. On 8/4/19, CBC showed platelet count of 11, so patient received 1 unit of platelets and then 2nd rituximab infusion. On 8/7/19, CBC showed platelet count of 14. MANY MORE TREATMENTS/OUTCOMES BUT COULD NOT FIT IN TIME LIMIT