Emergency Medicine Case Challenge: Bleeding Gums and Rash on Both Legs in a 38-Year-Old Man

Basma Abdulhadi, MD


April 12, 2023

Physical Examination and Workup

Upon physical examination, the patient is alert and oriented, hemodynamically stable, and not in any apparent distress. He has evidence of bleeding in his mouth and hemorrhagic blisters on his oral mucosa. He also has petechiae over his bilateral lower extremities, mainly on the legs.

Auscultation reveals that his lungs are clear bilaterally. Cardiac examination findings are within normal limits. No hepatosplenomegaly or lymphadenopathy is noted on his examination. Neurological examination findings are nonfocal.

Laboratory tests are as follows:

  • Hemoglobin level: 14 g/dL

  • White blood cell (WBC) count: 4500/µL

  • Platelet count: 15,000/µL

  • Red blood cell (RBC) count: 4.7 million cells/µL

Prothrombin time, partial thromboplastin time, international normalized ratio, and fibrinogen levels are all within normal ranges. Human immunodeficiency virus (HIV) test results and viral hepatitis serology findings are also negative.

A peripheral blood smear is obtained (a similar, example image is shown in Figure 2).

Figure 2.

Decreased platelets are noted without any platelet clumping. Megakaryocytes (large platelets) are also seen on the smear.


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