Heme/Onc

80 yo lady presents with a hematoma after a fall

Mary Guan on Jan 22, 2019 - University of Michigan

In the last 3 days, since her I+D of the breast hematoma, Ms. Brown has received 3 units of pRBCs with minimal improvement in hemoglobin each time (8-9, down from baseline of 12).  She remained hemodynamically stable and did not receive any FFP or PCC. Her platelets are also slightly lower than baseline, at 110s from 150s. In terms of drain output since the OR, drain output has been declining, from 140cc --> 91 --> 91 --> 24cc per day. 

Ms. Brown has no history of liver disease, bleeding disorders, easy bruising, spontaneous bleeding from other sites while on coumadin. No melena, hematochezia, chest pain, SOB, nausea/vomiting. No family history of coagulation disorders.

PMH: Atrial fibrillation, Cardiomyopathy, GERD, hypercholesteremia, hypertension, pulmonary HTN, squamous cell carcinoma, sick sinus syndrome

PSH: Mitral valve replacement, pacemaker placemenent, tonsillectomy, hysterectomy

Current medications include: Acetaminophen 650mg Q6H, Atorvastatin 10mg daily, Digoxin 125mcg daily, Diltiazem 120mg BID, Memantine 10mg BID, Omepraole 20mg daily, Propafenone 150mg Q8H, Silver sulfadiazine topical BID.

FH, SH are both non-contributory.

 

Physical exam is as follows:

BP 117/56, HR 90, T 37C, RR 18, SpO2 91% on RA

Gen: Tired appearing elderly woman, in NAD. Conversational.

HEENT: atraumatic, normocephalic, EOMI, MMM, no oral lesions

Neck: no cervical adenopathy; supple

Lungs: Increased work of breathing. Limited lung exam due to pt being in some distress and feeling tired.

Heart: Irregular rate and rhythm, 3/6 holosystolic murmur loudest at LLSB, no rubs or gallops heard. No JVP appreciated.

Abdomen: Soft, nontender, nondistended.

Extremities: Warm, no LE edema, distal pulses intact

Skin: Extensive bruising present over entire chest. 2 JP drains with small amount of blood. No rashes.

Neuro: AAOX3, moving all four extremities spontaneously. Forgetful.

BMP
136
4.8
103
35
1
24
Ca7.8
Mg2.1
Phos4.6
CBC
5
8.5
26.6
115
Coag
PT 9.5
PTT 23.6
INR 1.3
Liver Enzymes
AST 34
ALT 43
Alk 84
Bilirubin (total) 0.7
albumin 3.4

Continue to the next page!

In the last 3 days, since her I+D of the breast hematoma, Ms. Brown has received 3 units of pRBCs with minimal improvement in hemoglobin each time (8-9, down from baseline of 12).  She remained hemodynamically stable and did not receive any FFP or PCC. Her platelets are also slightly lower than baseline, at 110s from 150s. In terms of drain output since the OR, drain output has been declining, from 140cc --> 91 --> 91 --> 24cc per day. 

Ms. Brown has no history of liver disease, bleeding disorders, easy bruising, spontaneous bleeding from other sites while on coumadin. No melena, hematochezia, chest pain, SOB, nausea/vomiting. No family history of coagulation disorders.

PMH: Atrial fibrillation, Cardiomyopathy, GERD, hypercholesteremia, hypertension, pulmonary HTN, squamous cell carcinoma, sick sinus syndrome

PSH: Mitral valve replacement, pacemaker placemenent, tonsillectomy, hysterectomy

Current medications include: Acetaminophen 650mg Q6H, Atorvastatin 10mg daily, Digoxin 125mcg daily, Diltiazem 120mg BID, Memantine 10mg BID, Omepraole 20mg daily, Propafenone 150mg Q8H, Silver sulfadiazine topical BID.

FH, SH are both non-contributory.

 

Physical exam is as follows:

BP 117/56, HR 90, T 37C, RR 18, SpO2 91% on RA

Gen: Tired appearing elderly woman, in NAD. Conversational.

HEENT: atraumatic, normocephalic, EOMI, MMM, no oral lesions

Neck: no cervical adenopathy; supple

Lungs: Increased work of breathing. Limited lung exam due to pt being in some distress and feeling tired.

Heart: Irregular rate and rhythm, 3/6 holosystolic murmur loudest at LLSB, no rubs or gallops heard. No JVP appreciated.

Abdomen: Soft, nontender, nondistended.

Extremities: Warm, no LE edema, distal pulses intact

Skin: Extensive bruising present over entire chest. 2 JP drains with small amount of blood. No rashes.

Neuro: AAOX3, moving all four extremities spontaneously. Forgetful.

BMP
136
4.8
103
35
1
24
Ca7.8
Mg2.1
Phos4.6
CBC
5
8.5
26.6
115
Coag
PT 9.5
PTT 23.6
INR 1.3
Liver Enzymes
AST 34
ALT 43
Alk 84
Bilirubin (total) 0.7
albumin 3.4

Continue to the next page!

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