Case Report

(Laboratory interpretation report)

Name of clinician (student): _________________________________ Date: 2007 01 22.

Patient’s name: Sadder Budweiser.

Obese, 50 year old owner operator of the Fox and Fiddle bar and restaurant complains
that he vomited a large quantity, he says, of blood about 4 hours ago.
He complains that he has had severe epigastric pain over the last few days. This
occurred immediately after meals. Twice he had vomited his recent meals and the pain
was relieved.
He looks ill; he has severe pain in the upper abdomen and lower chest. He is sweating
profusely.

Additional information needed:

Temperature 36 oC
Pulse 130
Blood pressure 90/60
Weight 90 kg
Respiration 34.
Arcus senilis
Liver palpable 3 cm below costal margin. Smooth regular, not tender.
Epigastric tenderness, no rebound tenderness.
Clubbed fingers
Palmar erythema
Ankle oedema
Mild upper abdominal discomfort for 6 months
Appetite deteriorated lost 7 kg in weight
Smokes 30 cigarettes a day
“Social drinker”

Medical history winter bronchitis for the last 6 years

Four years ago had jaundice for 2 weeks. Told to reduce drinking.

JVP not raised

Pitting oedema of both ankles.
No ascites.
Melaena stool.
Relevant laboratory results:

Differential dx Test Healthy range Result Meaning

Gastric ulcer Haemoglobin 133 –177 96 g/L Chronic blood loss.
Haematocrit Iron deficiency anaemia.
MCV 80-100 fL 72
Wbc 4-11 x 109/L 10x 109/L
Platelet 150-450x109/L 300x109/L
Iron 14-31 umol/L 4
TIBC 45-70 umol/L 76
Ferritin 20-300 ug/L 7
Hypochromia
Anisocytosis GI bleed.
Serum urea 3-7 mmol/L 30
Gastric cancer CA 72-4 < 4 ug/L Negative No gastric cancer
TAG 72
Duodenal Pain two Negative for Negative Duodenal ulcer not
ulcer hours after antibodies to likely
meal Helicobacter
Ab H. pylori pylori
Alcoholic PT 11-15 seconds 17 second Liver disease, not icteric
cirrhosis ALT 5-35 U/L 50 at this stage.
ALP 10-100 U/L 120
GGT 11-50 U/L 75
Albumin 35-50 g/L 30
Acute Amylase 30-130 U/L 140 Pancreatitis possible
pancreatitis
CAD Troponin T <3ug/L 4 Some CAD possible
Myocardial
infarctions
Pulmonary PT 11-15 seconds 17 Pulmonary embolus not
embolus LD 140-280 U/L 300 likely.
D dimers <0.25 mg/L Negative
Underline the most likely diagnosis from the information given.
Comments:
GI hemorrhage most likely from gastric ulcer.
Could be gastric cancer but less likely. TAG-72. Increased in more than 50% of cancer
patients.
Duodenal ulcer different timing.
Acute gastric erosion could bleed but this is acute.
Occupation, history, hepatomegaly, clubbing and palmar erythema suggest alcoholic
cirrhosis.

Further diagnostic test(s) required and why.

X ray of abdomen
ECG
How should he be treated?
Send to ER. IV likely as shock may be close.