Severe non-traumatic bleeding, the answer is not in the blood

A 92-year-old woman presented to the Emergency Department (ED) with a wide hematoma on the left hemithorax starting from the anterior axillary line and extending to the back. She did not report any history of trauma (Fig. 1). The patient had a history of hypertension, vascular dementia, previous hip replacement complicated by immobilization syndrome with pressure ulcers and she had an indwelling urinary catheter. She was taking ticlopidine 250 mg twice daily and amlodipine 10 mg once daily. Cardiac, pulmonary and abdominal examinations were negative. Vital signs were within normal range: blood pressure 120/60 mmHg, heart rate 80 bpm and oxygen saturation 95 %. The patient was alert but uncooperative and not oriented. Laboratory tests showed severe normocytic anemia: hemoglobin 6 g/dL, mean corpuscular volume—MCV, 90 fL, absolute reticulocyte count of 12.3 9 10/lL, low serum iron and ferritin 30 lg/dL and 27 ng/mL, respectively, normal platelet count 302.000/mm, aPTT elongation 111 s, ratio 3.46, normal PT 11 s, ratio 1 and INR 0.8. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both increased: 73 mm/h and 3.71 mg/dL, respectively. Spine, left shoulder and hemithorax X-ray studies excluded bone fractures. Chest X-ray and abdomen ultrasound examinations were both negative. An electrocardiogram performed in the ED did not show relevant findings.