Marital Status Cohabiting Sex Male
3/52 hx of epistaxis, oral mucosal bleeding and purpura over the feet and shins.
JM was diagnosed with idiopathic autoimmune thrombocytopenia purpura in 1996. He suffered from epistaxis, bleeding gums and purpura and his platelet level at this time was found to be 2 x 109g/L. Treated with corticosteroids, but refractory to therapy, JM underwent a splenectomy with good resolution. He was gradually weaned off prednisolone and followed up in the haematology clinic in 1999. The patient has been asymptomatic until this recent presentation to his GP, who referred him to the haematology unit at the Western General Hospital.
1994 - Autoimmune haemolytic anaemia diagnosed. Treated with corticosteroids.
„aasthma, „aepilepsy, „ajaundice, „aDM, „aMI, „aCVA, „B, „aHT, „aRF
A call centre manager, JM lives in a semi-detached house with his partner and young son. He is a non-smoker and drinks only 5 units of alcohol a week. He has never taken recreational drugs. He has no significant risk factors for HIV infection.
General: JM has been feeling slightly more tired recently.
Denies any weight loss prior to admission
Denies any change in appetite or thirst
Denies nausea, vomiting or haematemesis
Denies any difficulty swallowing, dysphagia, indigestion or heartburn
Denies fresh blood or mucus in the stools
CVS: Denies breathlessness, chest pain and palpitations
Denies calf pain or ankle swelling
RS: 1/52 hx of cough with dirty sputum
Denies shortness of breath at rest, on mild exertion or lying flat
GUS: Denies incontinence or urgency
Denies nocturia, dysuria and haematuria
Loco: Denies pain, stiffness or swelling in any joints
Skin: 3/52 hx of painful rash over both feet extending over shins
Patient¡s Ideas, Concerns and Expectations
JM has a very good understanding of his condition and is v...