Balancing Functional Recovery and Medical Stability in Patients with Hematologic and Cardiovascular Comorbidities

Case Diagnosis: Hemorrhagic hematoma of the left lower extremity in the setting of trauma

Case Description or Program Description: Patient is a 61 year old female with past medical history of hypertension, HFrEF (LVEF 40-45%), aortic stenosis s/p TAVR, coronary artery disease s/p PCI, lupus, antiphospholipid syndrome, T2DM, and thyroid neoplasm s/p thyroidectomy who is s/p spontaneous drainage of a trauma-induced left leg hematoma at UMH. She was admitted to inpatient rehabilitation due to consequent impaired ADLs and mobility and participated in at least 3 hours of comprehensive therapy including PT/OT, speech therapy, and neuropsychiatric therapy along with medical management by PM&R.

Setting: Acute inpatient rehabilitation

Assessment/Results: The patient demonstrated significant improvements in functional abilities and strength, returning to baseline independence in mobility and ADLs in 11 days. Her rehabilitation required collaboration with hematology, dermatology, and endocrinology due to concerns about hematoma expansion, hemoglobin fluctuations, hypercoagulability, and persistently low platelet levels. To ensure a balance between functional recovery and medical stability, therapy intensity was modified daily based on clinical status and interdisciplinary discussion.

Discussion (relevance): Medically complex patients, such as this patient, benefit significantly from acute inpatient rehabilitation, but require a more cautious balance between functional recovery and medical stability. Determining the appropriate intensity of therapy for this patient was complex: excessive physical exertion risked hematoma expansion and further hemoglobin decline, while conservative therapy could delay functional recovery. Using an interdisciplinary approach and continuous modifications to individualize this patient’s recovery process – as opposed to standardized protocol – allowed for minimization of complex medical complications during her rehabilitation.

Conclusions: This case highlights the challenges of rehabilitating a patient with a significant hematoma and an underlying hypercoagulable state. By individualizing the therapy plan based on daily assessments and multidisciplinary input, it was possible to achieve functional recovery while minimizing risk of hematoma expansion or complication.