Professional Documents
Culture Documents
Athaya hafizhah
Fathimah azzahra
Renggo aning saputri
Wulandari
Zahrotul jannah
A 74 year old african american woman
enters your office with the complaint that
she has been developing bruises all over
her axtremities for the last several days.
She also has noticed that her stool seems
to be a lot darker. She describes it looking
almost like coffee grounds. She relocated
to your area to live with her daughter after
her home in galveston was destroyed
several months ago. This is her initial visit
to your office, as she had refills available
for all of her medications and previously
Her past medical history is notable for
being hypertensive, postmenopousal,
having an irregular heartbeat thath she
doesnt remember the exact name for, and
having a touch of diabetes and arthritis.
Her prescribed medications are
hydrochlorothiazide and warfarin. Her over-
the-counter medications include aspirin
which she started taking since moving to
your city, a multivitamin, acetaminophen
for her arthritis and ibuprofen for when her
knees really bother her. She also admits to
KEY WORD
1. A 74 year old
2. Bruises all over her axtremities
3. Stool seems to be a lot darker
4. Past medical history is notable for being hypertensive,
postmenopousal
5. Having an irregular heartbeat
6. She doesnt remember the exact name
7. Having a touch of diabetes and arthritis
8. Her prescribed medications are hydrochlorothiazide and
warfarin
9. Her over-the-counter medications include
aspirin,multivitamin, acetaminophen
10. She has take an ibuprofen for her knees
11. Regularly drinking herbal teas
DIFFERENTIAL DIAGNOSE
Symptoms:
- Easy to bleeding -> easily bruising
- Melena
- Trombositophenia
LIVER DISEASE
Symptoms:
- Jaundice
- Bleeding easily
- Lost of appetite
- Fatigue
- diarrhea
HEMOPHILIA
Symptoms:
- Hematoma leading to location-specific signs
VON WILLEBRAND DISEASE
Surname : -
First name : A
Age : 74 yo
Sex : Female
Marital Status : -
PRESENT COMPLAINT
1. General condition : -
2. ENT :-
3. RS :-
4. CVS : an irregular heartbeat
5. GIS : dark stool (melena)
6. GUS :-
7. CNS :-
EXAMINATIONS
Height
Weight
Estimation of blood pressure
Examination from head to toes
Examination of rectum (rectal touche)
Head to toes
Found :
Rectal
touche
found :
IMMEDIATE PAST HISTORY
1. Her past medical history is notable for being
hypertensive, postmenopousal, having an
irregular heartbeat thath she doesnt remember
the exact name for, and having a touch of
diabetes and arthritis.
2. Her prescribed medications are
hydrochlorothiazide and warfarin.
3. Her over-the-counter medications include aspirin
which she started taking since moving to your
city, a multivitamin, acetaminophen for her
arthritis and ibuprofen for when her knees really
bother her.
4. She also admits to regularly drinking herbal teas.
POINTS OF NOTE
No information
INVESTIGATION
1. Complete blood count :
Blood sample for haemoglobin
Blood sample for trombosit
Blood sample for blood group
2. Chemical blood count
3. Liver function
4. Kidney function include urin
5. Electrocardiography for her irregular heartbeat
6. Fecal occult blood test
7. Prothrombin Time (PT)
DIAGNOSIS