Transcript Slide 1
NYU Medical Grand Rounds Clinical Vignette Kristen Lee, PGY 2 May 13, 2009 Chief Complaint The patient is a 90 year old female who was transferred from a nursing home to the emergency room for evaluation of bright red blood per rectum for 24 hours. History of Present Illness Eighteen days before admission, she was diagnosed with right ileofemoral vein thrombosis. Enoxaparin was started and subsequently bridged to warfarin 5mg a day. After 1 week of warfarin therapy (9 days before her current hospitalization), her international normalized ratio (INR) was 2.5 One day prior to admission, she complained of bright red blood in her stool and she was found to have bleeding external hemorrhoids for which she was sent to the emergency room for further evaluation and treatment. Additional History Past Medical History – Chronic stable ischemic heart disease – Congestive heart failure – Hypertension – Hyperlipidemia Past Surgical History – Hysterectomy – cholecystectomy Social History – Former tobacco of 30 pack years – Social alcohol – Widowed, 3 children Additional History Continued Family History – Noncontributory Allergies – No Known Drug Allergies Medications – – – – – – Carvedilol 12.5 mg twice daily Lisinopril 20 mg daily Aspirin 81mg daily Furosemide 40mg daily Simvastatin 40mg daily Warfarin 7.5 mg daily Physical Exam General: Elderly female in no acute distress, oriented to person, place, time Vital Signs: HR:110 BP:128/64 RR:16 O2sat 99% on RA CV: II/VI systolic ejection murmur at the right upper sternal border Extremities: warm, tender, edematous right calf Rectal: large bleeding external hemorrhoids Remainder of the physical exam was normal Laboratory Findings CBC: – Hemoglobin of 9.6 g/dl (12.6 several days prior) – Platelets of 285 Basic Metabolic Panel: – BUN 46 – Creatinine 1.4 Hepatic Panel: within normal limits INR: 6.6 PTT: 180 Working Diagnosis Right calf cellulitis Lower gastrointestinal bleed External Hemorrhoids Unexplained coagulopathy Hospital Course Hospital Day 1: – Warfarin was discontinued – The patient was transfused 2 units of fresh-frozen plasma and 2 units of packed red blood cells – the INR fell to 3.7 and the hemoglobin rose to 13.5 – Vitamin K was administered IV – the hemorrhoids were ligated and she refused further investigation – IV cefazolin 500mg 4 times daily was initiated Hospital Course Hospital day 4: – the patient had a recurrent lower gastrointestinal bleed that resulted in another drop in hemoglobin from 13.5 to 9.5 g/dl – a repeat INR was unexpectedly 7.5 – Another 2 units of packed red blood cells was given and her hemoglobin rose to 13.1 – the hemorrhoids were ligated again Final Diagnosis Recurrent lower gastrointestinal bleed secondary to a coagulopathy of possible genetic origin