Discussant: Dr. Gary Weinstein
Resident presenter: Dr. Manavjyot Heer
CC: "My blood count is low"
HPI: This 83-year old white female was admitted to Presbyterian Hospital of Dallas electively for a newly diagnosed anemia and heme positive stool. The patient has lost eight to nine pounds in the last three months. One month prior to admission she had a stroke and was started on clopidogrel by her neurologist. Due to her recent stroke, she was admitted for a transfusion and a colonoscopy. She had no complaints at the time of admission.
PMH:
Medications: lisinopril 20 mg p.o. q.d., docusate sodium 100 mg p.o. q.d., aspirin 325 mg p.o. q.d., atorvostatin 10 mg p.o. q.d., diltiazem HCL 240 mg p.o. q.d., hydrochlorothiazide 12.5 mg p.o. q.d., and clopidogrel 75 mg p.o. q.d.
Social History: Lives with sister in Dallas. No alcohol, transfusions, or drugs. She does not smoke.
Review of Systems: negative
Physical Examination:
General: This is a thin, pleasant, elderly white female who is well and in no acute distress
Vital Signs: Blood pressure: 141/69. Temperature: 97.6 (F). Respirations: 18. Pulse: 102. Room air saturation of oxygen: 90%
HEENT: Pale sclera. No icterus.
NECK: No lymphadenopathy, thryromegaly, or JVD
CHEST: Clear to auscultation bilaterally
HEART: Mild tachycardia with regular rate and rhythm with a 3/6 systolic murmur heard best at the right 2nd intercostal space radiating into the neck.
Abdomen: soft, non-tender, non-distended, normoactive bowel sounds.
EXTREMITIES: No edema
NEUROLOGIC: Aphasia. Mild 4+/5 left-sided weakness
Data Base: White count of 6.4, hematocrit 25.7, hemoglobin 8.3, platelets 262,000, MCV 75.5. Normal differential. INR 1.1
Chest x-ray: Normal for age
EKG: Sinus rhythm at 99, normal axis. .5 to 1.0 mm ST depression in V4-V6. No Q waves. Good R wave progression.
Chemistry 14: Normal
Urinalysis: Normal
HOSPITAL COURSE: Two weeks prior to admission her Hemoglobin was 13. Given her tachycardia, recent stroke, ST changes on her EKG, it was felt that she should receive two units of packed red blood cells prior to her colonoscopy. During her transfusion, she was prepped for her colonoscopy with Go-Lytely.
She tolerated her first unit of blood well, but on initiation of the second unit she became hypoxic and hypotensive, prompting an immediate transfer to the intensive care unit. She was intubated, placed on dopamine and levophed. A Swan Ganz catheter was placed. The pulmonary capillary wedge pressure was 3, PA systolic 25 and PA diastolic 3. Cardiac Enzymes were within normal limits. The EKG was unchanged. An echocardiogram revealed an ejection fraction of 70 to 74%. Chest x-ray revealed marked bilateral opacities, which were not present on admission. A Blood count revealed a WBC of 0.8. Hemoglobin12.0. Platelets 260,000. The liver function tests remained normal except that the total protein fell to 4.0 and the albumin to 2.0 from 7.1 and 3.9 respectively, on admission. LDH was 439. Haptoglobin was 115. Her blood type was O positive.
Despite aggressive support, she died. An autopsy was performed.