A Really Bad Bruise

Theodore Black woke up two weeks ago with a massive bruise from the left side of his chest to his lower abdomen. He ended up admitted to the intensive care unit and wasn’t discharged from the hospital until today.

“Cough and rash”, was his chief complaint in my clinic schedule that morning. I had an emergency room report from Lakeside Hospital, near where he had spent a week at a conference. Two days before I saw him, he had gone to Lakeside’s ER with a nasty cough and pain across his lower chest and upper abdomen, radiating all the way around his mid-back like a vice. They got a normal chest X-ray, and a normal complete blood count and chemistry profile, so they sent him out with prescriptions for pain pills and some cough medicine.

“I’ve still got this really bad cough, and the pain hasn’t let up”, he started, “and when I woke up this morning, I had this rash…”

He lifted his shirt and exposed a massive bruise running along the left side of his body from the level of his nipple to his hip.

My mind raced into action as I listened to his heart and lungs, palpated his lymph nodes, examined his abdomen by inspection, auscultation, palpation and percussion. His breath sounds were slightly diminished at the base of his left lung, the bruised area was dense and extremely tender. His abdomen wasn’t very tender, except under the bruise, but he had some flank dullness on the right. He hurt too much on the left side to let me percuss him there, and he was unable to roll over on his left side to allow me to check if the right-sided dullness to percussion shifted with a chance in position.

His blood pressure was a little lower than usual, but his pulse was low – which was to be expected with the beta blocker he takes for his blood pressure.

I couldn’t remember the eponym for what he had, but I knew he had massive internal bleeding somewhere. In the back of my mind I thought I remembered retroperitoneal bleeding from coagulopathy or cancer, necrotizing pancreatitis or possibly intraabdominal bleeding.

I ordered a fingerstick prothrombin time, which came back normal at 1.0 and a CBC and a chemistry profile which I knew would be ready in just a few minutes with our new chemisty analyzer. I told him I’d be back as soon as the labs were done.

Back in the office I googled “flank ecchymoses” and saw the eponym I had forgotten, Grey Turner’s Sign. Everything I remembered or just instinctively knew about it matched the monograph I found.

His CBC came back first, and his hematocrit had dropped from 40 at Lakeside to 27 – definitely a massive bleeding. I went back in his room and told him that I not only wanted him to go to the hospital but that I didn’t want him going all the way there in a private car, but in the ambulance. Just as Autumn was calling the emergency dispatch number, Ted’s chemistries came back, with the lowest sodium level I have ever seen, 116 mg/deciliter. It had been 140 two days earlier.

I have seldom seen symptomatic hyponatremia, and the correlation between sodium levels in the brain and in peripheral blood isn’t very predictable, but the literature suggests that people with sodium levels as low as Ted’s are likely to be obtunded or having seizures. He seemed quite normal in that regard. Still, it made me feel good about my decision to recommend that he should go to the hospital via ambulance.

Ted had a chest CT angiogram, showing a modest amount of blood in his left chest cavity, but there was no bleeding or any other abnormality in his abdomen or pelvis on those scans. His pancreas and kidneys looked just fine.

They slowly corrected his sodium deficiency and watched him carefully, but he didn’t lose any more blood and he had no seizures or any other neurological symptoms.

In the end, after his long and likely very expensive hospital stay, he was discharged for the second time on pain pills and strong cough medicine.

The final diagnosis was “Hyponatremia secondary to volume loss from left hemothorax and extensive ecchymoses from severe cough”.

I had expected to hear bad news any day from the hospital, but my first and possibly only sighting of Grey Turner’s Sign turned out to be very benign. My colleagues were aware of my initial observations and this afternoon I walked around and told them how things had turned out.

“I’m sure someone will write that case up and publish it”, Dr. Brown said, probably referring to one of the major medical journals.

“Definitely”, I answered. I never did get around to telling Dr. Brown that I am writing this blog.

So, if The New England Journal of Medicine runs a piece on hyponatremia due to severe internal hemorrhage from coughing, you read it here first.

2 Responses to “A Really Bad Bruise”

  1. 1 Friendly guy February 26, 2016 at 12:37 pm

    Thanks for this post – it’s an interesting read.

    I’m not medically trained, so forgive the naivety of my question: why would a hemorrhage cause low sodium levels?

    Do the loose blood cells absorb sodium from the other tissues?

  2. 2 Faudes February 27, 2016 at 1:11 am

    You can initiate the publishing idea yourself or get involved in the process! Go on!!! Btw i love your blog!!!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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