CASE HISTORY

BY

DR. SIDDQUE AKBAR SATTI

MBBS,FCPSCONSULTANT PHYSICIAN

CAPITAL HOSPITAL ISLAMABAD

PAKISTAN

CASE PRESENTATION

Demographic Details

Mr. XYZ , 38yr old Male, Dental technician, Resident of

Rawalpindi, is admitted through E.R on 10- 12 -2012.

PRESENTING COMPLAINTS;-

Black colored stools......20 days

Shortness of breath ,,,,,,,5 days

HISTORY OF PRESENT ILLNESS;-

Patient was in usual state of health when he

started suffering from passing black colored stools of

soft consistency ,with frequency 1-2 times per day. There

was no history of haematemesis or fresh blood in stools.

There is also history of continuous NSAIDS use a month

before. No history of pain epigastrum ,heart burn ,nausea

or dyspepsia like feeling. Later on with the passage of

time patient start suffering from easy fatigability even

after milder exertion and also shortness of breath

on exertion which was of gradual onset ,progressive and

increased to such extent at time of presentation that

patient cant walk for 10 steps without rest. During this

period and also for about last 2 months he was also

suffering from small mucosal bleed from gums, that had

also increased in amount and frequency at time of

presentation. No other history of bruising of the skin nor

history of bleeding from other site.

PAST MEDICAL HISTORY;-

Not significant

PAST SURGICAL HISTORY;-

No history of any surgical procedure

FAMILY HISTORY;-

Patient has 2 brothers and 2 sisters

Father is diabetic and hypertensive

Mother was also diabetic and died of sudden

cardiac arrest

SOCIOECONOMIC HISTORY;-

Lab technician by profession with monthly

income of about 30,000 a month

lives in well lighted an ventilated home

PERSONAL HISTORY;-

Cigarette smoker.

No history of addiction to any drug or alcohol

Drug history

History of transfusion of whole blood for Anemia one

month back

SYSTEMIC INQUIRY

NAD

EXAMINATION

GPE

A young man lying comfortably in his bed, well oriented in

time , place and person.

VITALS:

Pulse : 90bpm, regular

BP : 130/70mmHg

Temp : 98.6 oF

RR : 16/min

Jaundice: -ve

Cyanosis: -ve

Koilonychia: -ve

Clubbing: -ve

Leuconychia: -ve

Ankle edema: -ve

Thyroid: Not enlarged

Lymhnodes Not palpable

CONT…(GENERAL PHYSICAL EXAMINATION)

Pallor: +ve

Bruises on Right thigh

CVS:- (Unremarkable)

CNS:- (Unremarkable)

GIT:- (Unremarkable)

RESPIRATORY SYSTEM:-

(Unremarkable)

SYSTEMIC EXAMINATIONS

D/D:-1. CLD

2. GASTRITIS

3.Coagulation disorder

INVESTIGATIONS CBC;-

Hb...............3.8 g/dl

TLC.............9400/cmm

RBCs............1.99 million /cmm

Hct................14%

MCV.............70.4 fl (77-96 fl)

MCH.............19.1 pg (26-32 pg)

MCHC...........27.1 gm/dl (32-36 gm/dl)

Platelets............480,000/cmm

PT;-

PT....................15 sec

Control............13 sec

INR.................1.20

APTT;-

APPT....................65 sec

Control............ 33 sec

BT.......................>15 min (Normal 2-11 min)

CT.......................05 min 13 sec (Normal 4-11min)

Hess test..............Negative

STOOL FOR OCCULT BLOOD ...........

Positive

Hepatic profile

S.Bilirubin...........0.7mg/dl

ALT....................38 U/L

GGT....................33 U/L

ALP ....................139U/L

HBsAg.......................Negative

HCV antibody............Positive

HCV PCR Qualitative.......Detected

USG ABDOMEN;-

Fatty liver

No evidence of CLD & Portal

hypertension

H.PYLORI ANTIBODY;-

IgM.....................Non reactive

IgG.....................Reactive

UPPER GI ENDOSCOPY;-

Esophagus normal

Multiple erosions at pre pyloric ,fundus,and lesser

curvature of stomach.

Small ulcler at anterior wall of 1st part of duodenum

and multiple duodenal erosions

Oozing of Blood ++

No oesophageal varices

VON WILLEBRAND AG FACTOR;-

.................7.9% (normal range 50-160)

Results are suggestive of type 1 von willebrand disease

Solubility test for factor X111.............Negative

TC-RBC LABELED STUDY FOR GI

BLEED;-

Scan appearance is suggestive of active bleeding from

stomache and proximal duodenum,moving through the

small intestine.

FINAL DIAGNOSIS

After investigations diagnosis

of vonwillebrand

disease type 1 was made.

TREATMENT

Inf. Esomeprazole 40mg ................ I/V BD

Inj Transamic acid 500mg................ I/V TDS

Transfusion of Red cell concetrate........ 40 pints

Transfusion of cryoprecipitates ……… 126 pints

H.Pylori eradication therapy

Humate P (Anti hemophilic Factor/von

Willebrand Factor Complex)

Loading dose of 40-75 units/kg IV, then 40-60

units/kg q8-12hr for 3 d.

Endoscopic APC(Argon Plasma Coagulation) was done

and bleeding was stopped .

Thank u