THE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.
She lives at home and has had no recent hospitalizations. Her medical history includes atrial fibrillation and a previous embolic cerebral stroke for which she takes warfarin(Drug information on warfarin). It has been at least a few months since her international normalized ratio (INR) was last checked.
The patient is in minimal discomfort and is afebrile. Heart rate is rapid, and rhythm is irregular. Systolic blood pressure is in the mid 90s. Chest shows no signs of trauma. Lung sounds are normal, with no crepitation or clinical evidence of rib fractures. There is a large (about 12 X 12-cm), firm, ecchymotic, exquisitely tender mass over the left side of the abdomen; no guarding, rebound, or peritoneal signs are present.
After further directed questioning, the patient reports that she had fallen in her bathroom a few days earlier.
What is the most likely cause of this patient’s symptoms?
• Idiopathic thrombocytopenic purpura
• Abdominal wall hematoma
• Thrombotic thrombocytopenic purpura
(Answer and discussion on next page.)