I had a patient last week I can't stop thinking about. Med-surg floor, 40 yr old female, admitted with SOB and fevers one week s/p a Thymectomy to treat myasthenia gravis. After the surgery she had had some complications and ended up having to have a left thoracentesis to remove 850cc fluid. Then, she went home for a few days before being readmitted with the SOB and fevers.
The day I had her (about 3 days after readmit), she looked a little pale and lethargic in the morning and was c/o right lung spasms when she breathed. Vitals normal, afebrile, O2 sat 97% on 3L NC. Pt slightly SOB, lungs diminished, but otherwise fine. However, Hgb was 7.9. Two days before it had been over 9. I called the MD and he ordered a CBC to be drawn later that afternoon to recheck it.
I gave the pt some IV dilaudid to help with the pain of the lung spasms, and besides being a little SOB, pt fine.
At 2:00, I draw the CBC and notice pt looking a little more pale with a slight bluish tinge to lips. Pt O2 sat 90% on 3L. Bump it to 4, call respiratory for a treatment and take the CBC to lab. 20 minutes later lab calls me to report Hgb of 5.9!
Called the MD with the results (who was just as surprised as I was) and he ordered some tests, 2 units blood, etc.
Go into room and find patient extremely SOB, anxious, bluish lips, pale, O2 sat 88% on the 4L. Bump the O2 to 6L and called a rapid response.
Pt ended up being transferred to the unit.
My question - where on earth was this lady bleeding?? No apparent GI bleed, pt's abdomen soft and flat, pt had just had a lung xray that morning that was unchanged from the previous days xray (moderate pleural effusions). I've never seen a Hgb drop that fast. I am relatively new and want to know if I am missing something obvious (if I am, please don't be mean to me, I want to learn)
Also, I don't know if this is related at all, but when I drew patient's lab, her blood was SO THICK and dark, it was like trying to get chocolate pudding out of her veins.