1. Case presentation By Shimaa Gamal

2. Personal history:
male patient named Abd-Elgawad Shokry Elsayed ,22 years old , from zefta ,student , single , no special habit of medical importance .

3. Complaint:
Bleeding per gums 1 week ago. Bleeding per nose 5 days ago.

4. Present history: The condition started 1 week by gradual onset progressive coarse of bleeding per gums started with teeth brushing then gradually progressed to become spontaneous . 2 days later , he developed epistaxis associated with blood clots ,not preceded by trauma & was bilateral & painless .

5. The condition was associated with purpuric eruption. in L
The condition was associated with purpuric eruption in L.Ls which was non raised , non painful , violacious , small sized skin rash .
This condition was not associated with prior drug intake .
The condition was associated with dyspnea of gradual onset , progressive course , increase with exertion , partially relieved by rest & associated with easy fatigability but he denied having orthopnea , PND or chest pain .

6. The patient saught medical advice at benha university hospitals at ED where ENT consultation was done & there was no local cause for epistaxis & packing was done then the patient was admitted to internal medicine department .
No history of alopecia , malar photosensitivity .
No history of arthralgia or arthritis .
No history of abdominal pain or jaundice .
No history suggesting DVT .
No history of dysuria ,hematuria or dark urine.
No history of motor , sensory , cranial nerve or sphencteric affection.
No history suggesting swelling at anatomical sites of L.N.
The patient is neither diabetic nor hypertensive .

7. past history:
No history of operation ,no history of drug intake or blood transfusion
No history of T.B or Bilharziasis.
No history of allergies.

8. Family history:
No similar condition in his family.
-ve consanguinity.

9. Examination: Vital signs:
Pt is cooperative , fully conscious ,lying flat in bed, oriented to time, place and persons.
He looks ill .
MMS 28/30 .
Complexion : pallor.
BMI:60/1.70 (20.8)
Vital signs:
Blood pressure: 110/70 mmHg in supine position in Rt arm.
Pulse: 95 beat/min, regular, equal on both side, average volume, no special ch.ch ,peripheral pulsations are felt.
RR: 16 cycle /min.
Temperature: 39˚c by oral route.

10. Head & neck: pallor . Lt sided sub conjunctival hemorrhage .
No cyanosis, no jaundice.
No congested neck veins.
No thyroid swelling.
Trachea is central.
No L.N enlargement.

12. Upper limb: Lower limb: Pallor.
Bilateral ecchymotic patches which are variable in size ,dark blue in color ,non elevated ,non tender & associated with purpuric eruption small sized ,violacious in color ,non elevated ,non tender .
No clubbing , no cyanosis .
No deformity.
Lower limb:
Ecchymotic patches & purperic eruption as discribed in upper limbs.
No signs of DVT ,no edema ,no clubbing.
No L.N enlargment.

15. Chest examination Inspection: Palpation: Symmetrical.
No scars, No pigmentation.
No dilated veins.
No sternal tenderness.
Palpation:
Trachea is central.
No tenderness.
Normal TVF

16. Percussion: Auscultation: No dullness .
Upper border of liver at 5th intercostal space MCL
Auscultation:
Fair and equal air entery ,
No additional sounds.

17. Cardiac examination Inspection &palpation:
Apex at lt 5th intercostal space MCL.
No pulsations are felt.
Percussion:
No dullness outside apex, pulmonary , aortic areas
Auscultation:
accentuated heart sounds , no additional sound, no murmur.

18. Abdominal examination
Inspection:
No scars, No pigmentation
Normal abdominal contour
Umbilicus is inverted
Normal subcostal angle
No divercation of recti
No visible vessels or masses
No pigmentation or scratching marks.
Palpation:
No tenderness or rebound tenderness.
No organomegally.
Percussion:
No ascites.

19. Neurological examination: Free .
Locomotor systym examination: Free.

20. Investigations CBC Hb: 6.7gm/dl MCV: 90FL MCH: 30pg
WBCs: 2200 ( neutrophils : 500 ,
lymphocytes :1500 )
PLT: zero (manual count 1000)
ESR: 150 mm/h
RBS: 103

21. S.creatinine: 1.2 mg/dl
Bl. Urea: 32
S.Na: 139 meq/dl
s.k: 3.8 meq/dl
s.albumin: 3.7
PT: PTT:41 INR: 1
ALT: 22
AST: 26
CMV Igm : -ve
EBV Igm : -ve
Hebatitis markers : -ve

22. Blood film : RBC`s : normocytic normochromic anemia.
WBC`s: leucopenia with severe neutropenia &
relative lymphocytosis.
platelet: severe thrombocytopenia.
No blasts could be seen.

23. Bone marrow : hypo cellularity of all series A picture suggestive of
aplastic anemia

24. Thank you