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Answers on p 57.
A 58 year old unemployed man was admitted as an emergency with a two week history of gum bleeding and a one day history of gross haematuria. Other than osteoporosis and low back pain his past medical history was unremarkable. He had had previous dental extractions and major surgery without any excessive bleeding. He did not have a family history of a bleeding disorder. His diet was normal and contained vegetables and fruit. His weight was stable, his appetite was good, and he had no bowel symptoms. Regular drug ingestion was confined to co-codamol, Distalgesic, and diazepam. His alcohol intake was less than 10 units/week. Clinical examination was unremarkable and he had no purpura or echymoses, no hepatosplenomegaly, and no signs of chronic liver disease.
His blood test results on admission were as follows:
Full blood count—haemoglobin 14.7 g/dl, white cell count 12.5 × 109/l, platelet count 222 × 109/l.
Clinical chemistry—creatinine 113 μmol/l, glucose 5.0 mmol/l, adjusted calcium 2.35 mmol/l, aspartate transaminase 17 U/l, alanine transaminase 18 U/l, bilirubin 5 μmol/l, γ glutamyl transferase 45 U/l, albumin 39 g/l.
Prothrombin time 230 s (normal range 9.5–11.5 s).
International normalised ratio (INR) 25.5.
Prothrombin time + 50% normal plasma 9.5 s.
Activated partial thromboplastin time (APTT) 116 s (normal 27–36).
APTT + 50% normal plasma 49.3 s.
Thrombin time 18.6 s (normal 18–23).
Fibrinogen 7.7 g/dl (normal 1.7–3.3).
- What is the differential diagnosis?
- What is the most likely diagnosis and how would you prove it?
- How would you treat this patient?