CASE REPORT
A 22-year-old male presented to the emergency room of our hospital with
slight dizziness, four episodes of vomiting mixed with blood and passage
of dark stool over a 48-hour period. The patient had no prior history of
chronic alcoholism, liver cirrhosis or hepatoma. According to the
patient, he has had an episode of vomiting of blood and abdominal pain a
year ago and was treated and discharged on account of bleeding peptic
ulcer disease. This current episode of vomiting of blood with slight
dizziness occurred again and was brought to our hospital by his parents
for further management.
Upon physical examination, patient appeared pale with no evidence of
respiratory distress. There was no complaints of cough, chills, headache
or fever. No obvious abdominal mass palpated.
Vital signs: Blood pressure: 143/96mmHg, Heart rate: 100beats/minute,
Temperature: 36.9oC, Respiratory rate: 15
breaths/minute, Oxygen saturation: 97%.
Based on the patient’s clinical presentation, an initial diagnosis of
bleeding peptic ulcer disease with differential diagnosis of
Mallory-Weiss tear was made.
Laboratory investigation was then initiated and highlighted as follows:
There was evidence of severe anemia (low hemoglobin and red blood cells
(RBC)), low platelets, low hematocrit (HCT) and low mean corpuscular
volume (MCV) upon full blood count investigation