9. Findings and Hospital Course over the first 72 hours

1) Anemia

  • Transfusion of 3 units of RBCs increased the Hct to 25.6%.
  • Direct and Indirect Coomb's both negative (done on original sample).
  • LDH and total bilirubin did not increase further and subsequently declined to normal range.

2) Coagulopathy

  • Mixing study completely corrects the prolonged PT and PTT.
  • PT/PTT both normalized after 3 days of parenteral vitamin K. PT 11.9 sec (control 12.2 sec) PTT 26.2 sec
  • Fibrin split products < 10, Fibrinogen remains > 600.
  • Bleeding time 5.5 minutes.
  • The abnormal coagulation tests can be explained by vitamin K deficiency.

3) Hematoma

  • Doppler ultrasound negative for DVT/aneurysm/tumor.
  • MRI shows no vascular abnormalities or unusual structures; the hematoma appeared to have started within the knee (intra-articular) and then extended into the soft tissue of the thigh.

4) GI symptoms and fever

  • Nausea, vomiting, and abdominal pain were observed to be exacerbated by PO intake in the hospital.
  • Abdominal CT revealed a distended gallbladder, dilated common bile duct, and fluid in the gallbladder fossa.
  • GI consultation suggests chronic cholecystitis secondary to stone, tumor, stricture, or spasm from chronic morphine use. The fluid surrounding the gallbladder fossa could be from a resolving hematoma.
  • ERCP confirms the CT findings of a diffusely-dilated biliary tree but fails to identify a cause.
  • Laparoscopic cholecystectomy is successfully performed - culture of specimen is negative.
  • Blood cultures and throat swabs show no bacterial pathogens.