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Case Abstract Ruilan, li Female 65y

Case Abstract Ruilan, li Female 65y. From: Department of gastroenterology 06/01/2006. Chief complaints . Intermittent hemorrhage in gingival mucosa for one year, epigastric bloating for two weeks and hematemesis for six days. History(1) .

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Case Abstract Ruilan, li Female 65y

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  1. Case AbstractRuilan, li Female 65y From: Department of gastroenterology 06/01/2006

  2. Chief complaints • Intermittent hemorrhage in gingival mucosa for one year, epigastric bloating for two weeks and hematemesis for six days

  3. 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.

  4. 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.

  5. 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

  6. History(4) • Treated with transfusion, anti-acid, somatostatin at emergency room. • No hemetemesis any more. • Endoscopy: esophageal varices , no active bleeding; chronic gastritis

  7. Past history: deny hepatitis or parasite infection. • Personal history：deny alcohol abuse, cigarette. • Marital and menstrual history: no special. • Family history: one daughter HbsAg(+).

  8. 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

  9. Primary diagnosis • Upper gastrointestinal bleeding esophageal varices rupture Chronic hepatitis B hepatocirrhosis esophageal varices spleenomegaly Child B Chronic gastritis

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