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
