I recently had two patients that presented with similar yet vague symptoms with two very different outcomes.

The first patient was a 70s-year-old female with a history of rheumatoid arthritis and hypertension who presented after finding dried blood in her mouth throughout the day. She denied any oral and dental injury or pain. She could not identify a source of the bleeding and did not feel any active bleeding. She had no associated symptoms, no melena or any other evidence of bleeding. She had no changes in her medications, but she is on methotrexate for her RA. Her physical exam was significant for dried blood in her oropharynx without an identifiable source. Her exam was otherwise benign. Lab work was significant for platelet count of 3, but otherwise normal. She was admitted for suspected ITP. On follow-up, she was later diagnosed with methotrexate toxicity. Her platelets improved after holding her home medications.

Second patient was an 80s-year-old female with severe dementia and hypertension. She was brought in by her son with whom she lives. The patient was unable to participate in her history or exam. He stated that when he went to get her out of bed that morning, he noticed dried blood in her mouth. Again, no trauma or source of bleeding was identified. She had no observed hematemesis or hemoptysis. Otherwise, history was unremarkable other than gradual weight loss secondary to poor intake. Exam was only significant for small amounts of dried blood in the oropharynx. Her mental status was at baseline. Lab work was insignificant. However, a chest x-ray showed a previously unknown left middle lobe mass. After a long discussion about goals of care with the son, the patient went home with plans for hospice care.

I found the juxtaposition of these two patients interesting as both had a vague, non-classic complaint with a generally benign exam.