Case Study#2

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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

• 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

• 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

• 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

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