1. CASE HISTORY
BY
DR. SIDDQUE AKBAR SATTI
MBBS,FCPS
CONSULTANT PHYSICIAN
CAPITAL HOSPITAL ISLAMABAD
PAKISTAN

2. CASE PRESENTATION
Demographic Details
Mr. XYZ , 38yr old Male, Dental technician, Resident of
Rawalpindi, is admitted through E.R on 10- 12 -2012.

3.  PRESENTING COMPLAINTS;-
 Black colored stools......20 days
 Shortness of breath ,,,,,,,5 days

4.  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

5.  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.

6.  PAST MEDICAL HISTORY;-
 Not significant

7.  PAST SURGICAL HISTORY;-
 No history of any surgical procedure


8.  FAMILY HISTORY;-
 Patient has 2 brothers and 2 sisters
 Father is diabetic and hypertensive
 Mother was also diabetic and died of sudden
cardiac arrest

9.  SOCIOECONOMIC HISTORY;-
 Lab technician by profession with monthly
income of about 30,000 a month
 lives in well lighted an ventilated home

10.  PERSONAL HISTORY;-
 Cigarette smoker.
 No history of addiction to any drug or alcohol


11. Drug history
 History of transfusion of whole blood for Anemia one
month back

12. SYSTEMIC INQUIRY
 NAD

13. 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

14. CONT…(GENERAL PHYSICAL EXAMINATION)
Jaundice: -ve
Cyanosis: -ve
Koilonychia: -ve
Clubbing: -ve
Leuconychia: -ve
Ankle edema: -ve
Thyroid: Not enlarged
Lymhnodes Not palpable

15.  Pallor: +ve
 Bruises on Right thigh

16. SYSTEMIC EXAMINATIONS
CVS:- (Unremarkable)
CNS:- (Unremarkable)
GIT:- (Unremarkable)
RESPIRATORY SYSTEM:-
(Unremarkable)

17. D/D:-
1. CLD
2. GASTRITIS
3.Coagulation disorder

18. 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

19.  PT;-
 PT....................15 sec
 Control............13 sec
 INR.................1.20
 APTT;-
 APPT....................65 sec
 Control............ 33 sec


20.  BT.......................>15 min (Normal 2-11 min)
 CT.......................05 min 13 sec (Normal 4-11min)
 Hess test..............Negative

21.  STOOL FOR OCCULT BLOOD ...........
Positive

22.  Hepatic profile
 S.Bilirubin...........0.7mg/dl
 ALT....................38 U/L
 GGT....................33 U/L
 ALP ....................139U/L


23.  HBsAg.......................Negative
 HCV antibody............Positive
 HCV PCR Qualitative.......Detected

24.  USG ABDOMEN;-
Fatty liver
 No evidence of CLD & Portal
hypertension

25.  H.PYLORI ANTIBODY;-
 IgM.....................Non reactive
 IgG.....................Reactive


26.  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

27.  VON WILLEBRAND AG FACTOR;-
.................7.9% (normal range 50-160)
 Results are suggestive of type 1 von willebrand disease

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

29.  TC-RBC LABELED STUDY FOR GI
 BLEED;-
 Scan appearance is suggestive of active bleeding from
stomache and proximal duodenum,moving through the
small intestine.

30. FINAL DIAGNOSIS
After investigations diagnosis
of vonwillebrand
disease type 1 was made.

31. 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

32.  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.

33.  Endoscopic APC(Argon Plasma Coagulation) was done
and bleeding was stopped .

34.  Thank u