Case Abstract Ruilan, li Female 65y From: Department of gastroenterology 06/01/2006.
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Transcript of Case Abstract Ruilan, li Female 65y From: Department of gastroenterology 06/01/2006.
![Page 1: Case Abstract Ruilan, li Female 65y From: Department of gastroenterology 06/01/2006.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649e8f5503460f94b92a9c/html5/thumbnails/1.jpg)
Case Abstract
Ruilan, li Female 65y
From: Department of gastroenterology
06/01/2006
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Chief complaints
Intermittent hemorrhage in gingival mucosa for one year, epigastric bloating for two weeks and hematemesis for six days
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History(1)
Intermittent gingival bleeding for one year, usually during brushing teeth, without rhinorrhagia, petechia, ecchymosis, hematuria,hematochezia, and melena. No therapy.
Middle and upper abdominal floating for two weeks , accompanied with nausea, no relationship to meal , without heartburn , vomitting , abdominal pain , hematochezia, and melena. The symptom could not resolve after using Motilium.
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History(2)
Hematemesis occurred after taking hot food six days ago, for four times, about 1000ml; accompanied with nausea, vomiting , dizziness, palpitation, fatigue and diaphoresis.
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History(3)
At emergency room Vital signs stable CBC: WBC 10.09*10^9,Hgb 101g/l,Plt 77*10^9/l Biochemistry: ALT 35 U/l, Tbil 0.9mg/dl PT+A: PT 16.3s Alb: 2.5mg/dl HbsAg(+) Ultrasonic: spleenomegaly, no abdominal effusion
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History(4)
Treated with transfusion, anti-acid, somatostatin at emergency room.
No hemetemesis any more. Endoscopy: esophageal varices , no active
bleeding; chronic gastritis
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Past history: deny hepatitis or parasite infection. Personal history : deny alcohol abuse,
cigarette. Marital and menstrual history: no special. Family history: one daughter HbsAg(+).
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Physical examination
vital signs:BP 125/60mmHg, P 85, T 36,R 20; varicosity on abdominal wall, spleenomegaly , pittable edema on both legs , palmer erythema (-), spider angiomata ( - ), shift dullness ( - ) , flutter trembler ( - ) , normal on psychological and mental test
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Primary diagnosis
Upper gastrointestinal bleeding
esophageal varices rupture
Chronic hepatitis B
hepatocirrhosis
esophageal varices
spleenomegaly
Child B
Chronic gastritis
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