The Signs That Can’t Be Ignored

For several days, a 60-year-old man has been feeling weak. He has also noticed that he bruises easily, and he’s experienced black, tarry stools and episodic hemoptysis. He presents to the emergency department, where the triage team sends him for further evaluation.

The patient’s history is significant for a remote diagnosis of a deep venous thrombosis in one of his lower extremities, for which he takes warfarin. He does not recall his most recent INR level. He reports smoking up to one pack of cigarettes per day and consuming alcohol regularly.

Examination reveals an older appearing male in no obvious distress. His blood pressure is 90/60 mm Hg, and his heart rate is 110 beats/min. You note bruises on both arms. The rest of his physical exam is normal. Lung sounds are clear.

Labwork ordered by the triage team indicates a hemoglobin level of 8 g/dL and an INR of 9. In addition, his stool guaiac test came back positive.

You obtain a portable chest radiograph (shown). What is your impression?