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?