NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand RoundsClinical Vignette

• Kristen Lee, PGY 2
• May 13, 2009

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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.

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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.

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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

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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

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Physical Exam

• General Elderly female in no acute distress,
  oriented to person, place, time
• Vital Signs HR110 BP128/64 RR16 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

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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

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Working Diagnosis

• Right calf cellulitis
• Lower gastrointestinal bleed
• External Hemorrhoids
• Unexplained coagulopathy

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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

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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

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Final Diagnosis

• Recurrent lower gastrointestinal bleed secondary
  to a coagulopathy of possible genetic origin