The patient is a 49 year old white female with no significant past medical history who was admitted to the NCC with visual loss, diplopia, and weakness in her right arm. She was diagnosed with multiple emboli in the anterior and posterior circulation by MRI of the brain. Echocardiography revealed vegetations on the aortic valve. She received heparin for 6 hours but then it was held when the HCT dropped from 27 to 22. She was treated with packed RBC’s and sent to this institution.

PMH: Lack of appetite, and vaginal discharge in the past.

VS: BP-101-119/60-32, resp-24-15, Temp 39C, Saturation 93%- 98%/4L

PE: Gen: middle aged slightly obese sleepy, but arousable, answering questions but confused about place, time
HEENT: NC/AT
Lungs: CTA from front side of chest
Heart: RRR, no M/R/G
Abd : obese, distended, palpable mass in abdomen/pelvis
EXTR: no c/c/e, left colder than right
Neuro: ptosis, cortical blindness, moves right arm and leg but weak, lost ability to move left arm and leg.

1. What is your differential diagnosis?

2. What additional testing do you want?

3. Why did the hematocrit drop?