History of Present Illness:
A women in her mid 60’s with a history of hypertension and hypothyroid presents to the hospital for 1 week of worsening DOE and fatigue with occasional syncope even while sitting. She denies any chest or abdominal pain, nausea, vomiting, melena or other complaints.
Vital Signs & Physical Exam:
Vital signs are normal. Skin is pale, lungs are clear, no leg edema
Initial Diagnostic Testing:
- ECG: NSR at 77 with LVH
- CBC: Hb 7.4 with normal MCV, platelets 33,000
- Chem 7: Normal but AST 125, ALT 67, bili 1.2 and alk phos 297
- Other: INR 1.7
What is the most likely diagnosis?
- A) Iron deficiency anemia
- B) TTP
- C) Vasovagal syncope
- D) DIC
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What is the most likely diagnosis?
- A) Iron deficiency anemia – unlikely with a normal MCV
- B) TTP – good thought but doesn’t have other findings
- C) Vasovagal – not with that degree of anemia
- D) DIC – CORRECT
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CASE CONCLUSION: Fibrinogen low at 78 and d-dimer high at 3.14. Guaiac negative and colonoscopy negative. Ruled out for PE as well. She was diagnosed with indolent DIC from multiple liver tumors discovered during admission. No primary tumor found during admission.
CASE LESSONS:
- DIC can present indolently, especially when from malignancy