This go-around, we’ll learn a little about the basic bloodwork your doctor orders, and about another fundamental truth of human nature that can confound effective health care providing. Note that I saw this patient just this week.
51 year old white woman presented with weakness and dizziness. This is one of the more common chief complaints we see in the urgent care. The weak and dizzy (w/d) patient we get is almost always a female, age 40-70, often with no physical sickness causing it. Usually, it’s just some combination of stress and dehydration. But you still have to rule out everything else.
“Shirley” said she’s been feeling like this for two weeks. Her dizziness comes and goes, and was not related to change of position such as from lying to sitting up. The weakness and fatigue were constant and worsening. She also had vague aches throughout her body. She denied any other issues such as fever, ear pain or fullness, other recent illness, any other pains, trouble breathing, numbness, change in vision or hearing, nausea, vomiting, diarrhea, rash, change in urination.
The patient also denied any recent travel anywhere. She stated she kept herself well-hydrated — however, her appetite had gone down those past two weeks. She said she had no medical problems other than gout, which was well controlled with allopurinol. She did not take any other medication.
While discussing this with the patient, I told her something felt not right with this, and that I wanted to check labs. I explained that some conditions such as thyroid disease or anemia can cause her symptoms as well.
At this point, Shirley then told me her primary care doctor had already checked labs last week and told her that her hemoglobin was “in the sixes.”
Hemoglobin is the basic measure of whether or not you are anemic. Healthy women generally run in the 12 to 14 hemoglobin range or thereabouts. Women with chronic anemia, usually from iron deficiency, can go as low as 10. Anything less means trouble. Shirley was now claiming she was below 7.
Note that she had also failed to mention it until I had specifically brought up anemia. I asked what her primary care doctor did about this finding, and Shirley was a bit evasive, saying she had an appointment with a hematologist later. That’s it? Her blood drops to six-point-something out of nowhere and her PMD blows her off with an outpatient referral?
Shirley was adamant that she did not have any history of anemia, iron-deficiency or otherwise, prior to this and that she felt fine before two weeks ago. She again said she has no real medical problems other than her mild gout.
Low hemoglobin means one of two things: either not enough of the red stuff is getting into your blood vessels, or else too much of the red stuff is leaving them. I told Shirley this, and asked her if there were anything different with her stools. She told me that she had thought about that, but there was no blood when she went to the bathroom. Nor were there any “black and tarry” stools, which is what they look like when mixed in with dried or digested blood. She denied any bleeding or spotting from her vagina, coughing up blood, easy bruising or bleeding, or any mysterious swelling of her gut (from internal bleeding or otherwise).
I told Shirley that I was at a bit of a loss with this sudden and severe anemia out of nowhere and with no apparent bleeding or other symptoms. Anemia from lack of blood production tends to build up slowly over months or years, usually due to some other chronic condition, but the patient was telling me there was no cause for it. Such a crash in hemoglobin production over just a few weeks without a clear explanation does not come from anything that isn’t, well… dreadful.
So, I drew stat labs (including some basic tumor markers) and sent them off to try and get to the bottom of this. In a hospital, such labs come back in less than an hour. But in an outpatient setting such as an urgent care, we are lucky to get them back the same day. Her labs didn’t show up until the next day, today, when a colleague was working. Here is what we got. Some labs are still pending as of this writing.
WHAT IS YOUR GUESS AS TO THE PRIMARY DIAGNOSIS?
First, here are the labs. (click to enlarge)
To people who don’t work in a medical field, these are nonsense scribblings. But these are also the way labs have been handwritten on medical charts for generations. With the advent of electronic medical records, these will eventually go the way of the diagnostic peritoneal lavage or the Swan-Ganz catheter.
These diagrams are known as the “fishbones” and are used to convey the two most fundamental labs drawn: the complete blood count, or CBC; and the basic metabolic panel, or BMP, also known as the Chem7.
The CBC, as you can probably guess, is used to measure anemia; it is the four-armed thingamagigger in the middle. The left number is the white blood cell count; white cells fight infections, and so this goes high during infective illness. (9.05 is within normal limits.) The number in the top is the hemoglobin discussed earlier, and as you can see, her number is 5.2. This is even worse than “in the sixes.” But that is not what had us have her rush to the hospital.
The fishbone on the left is the BMP. It measures various electrolytes and other things in the blood that are not directly related to the blood cells of the CBC. Sodium and potassium show up here. So does something called creatinine, which is a measure of kidney function. It is the third number on the bottom, and should generally be not much more than 1.0 in the normal, healthy person.
Shirley’s number was 12.29.
DIAGNOSIS: ANEMIA SECONDARY TO END-STAGE RENAL DISEASE. (ESRD)
“End-stage renal failure” is a polite way of saying “your kidneys don’t do jack, and you need to be on dialysis.” Which Shirley was started on by the end of the day.
Anyone who has an interest in professional cycling will know what “erythropoetin,” or “epo,” is. This is the hormone used to trigger production of your red blood cells. Without it, you will suffer major anemia due to simple lack of red blood cells. And guess which organs make epo? That’s right, the same organs which had gone and quit with Shirley: the kidneys. No epo means no red blood cells. So we have our answer.
To the anemia, at least. It will take some time to figure out what caused her kidneys to fold like a bad poker hand. None of the most common causes were in play here: diabetes, high blood pressure, lupus, congenital illness. They will do biopsies to figure out which of the many kidney diseases were the culprit, but in the end this will be just academic. Shirley will be on dialysis until she gets a kidney transplant.
But Shirley’s denial was the biggest obstacle to the diagnosis. You see, she knew she had had kidney failure for some time now. Her primary care doctor had tried, again and again, to get her in touch with a kidney doctor. Each time, she had failed to show for the appointment. Each time, it was for the exact same reason that she repeatedly denied she had any sort of medical problem to me: the force behind why Lindsay Lohan insists she doesn’t have a problem. She felt that if she just ignored the problem, it would just go away, which works about as well with kidney disease as it does with your rent or your taxes.
The medical interview depends on the patient being honest. It is a rare privilege that doctors enjoy, one envied by cops, lawyers and journalists. Of course, we learn that drug seekers and other malignerers will lie; but other than those obvious examples, med school doesn’t really prepare you for people who lie about their problem because they just can’t come to terms with it. It’s something you learn on the job.
And I get why Shirley had a tough time with her problem. ESRD is no laughing matter. Beyond the tiresome, hours-long, 3x-week dialysis sessions, there are many, many other health reasons why depending on dialysis does not lend itself to a normal lifestyle. She probably knew that there was a strong chance the kidney doctors could do little to stave off her ESRD, and wanted to just live her normal life without thinking about it.
I get it. I can’t say I wouldn’t have the same reaction myself to such a grave diagnosis.
In the end, kidney failure certainly was on my differential, which is why I ordered epo levels on her as well as the other labs. But if I had known the truth, I would have sent her to the hospital straight-away. People, it’s counter-productive to lie to your lawyer, and unless you’re trying to scam some Percocets, it’s even more counter-productive to lie to your doctor. We have to have all the info to come to a logical conclusion without ordering thousands of dollars of tests, and besides, you are protected under HIPAA and doctor-patient confidentiality. And here in the grubby, low-end confines of an urgent care, we certainly are not of a judgmental mindset. Please tell us what’s really wrong. And then we can try to fix it.