Working Impression

45 y.o. woman with 1) severe anemia and 2) coagulopathy with a 3) right lower extremity hematoma and concurrent symptoms of 4) fever, 5) nausea, vomiting, and abdominal symptoms.

1) Anemia

  • significant blood loss into the soft tissue of the leg
  • some evidence for extravascular
  • hemolysis: ­ bili, ­ LDH but rare spherocytes and no evidence of free hemoglobin in the serum
  • hemolysis could be explained by "reabsorption" of the hematoma
  • no evidence of myelosuppression with high retic count
  • PLAN: check direct and indirect Coomb's and transfuse with RBCs

2) Coagulopathy
  • DIC unlikely since normal fibrinogen and platelet count and no shistocytes.
  • Normal liver enzymes
  • Earliest sign was prolonged PT; suggests severe vitamin K deficiency
  • PLAN: mixing study with repeat PT, PTT, check DIC profile, give vitamin K SC if the repeat PT is high and corrects with mixing

3) Hematoma
  • could be a primary, acquired bleeding disorder
  • DVT/aneurysm possible with subsequent rupture or tumor-related
  • occult trauma
  • PLAN: Doppler ultrasound and CT/MRI of lower extremity

4) Fever
  • DVT with secondary infection
  • Malaria or other bloodborne infection (recent travel history but in US)
  • Viral infection associated with autoimmune hemolytic anemia (HBV, EBV, CMV)
  • Lymphoproliferative disorder
  • PLAN: Pan-cultures, CT/MRI of abdomen and pelvis

5) GI symptoms
  • Dysphagia may be related to MS
  • Post-prandial symptoms point to gallbladder
  • PLAN: Abdominal CT/MRI for liver and gall bladder