The Case of the Chinese Canary

[RustedFox]

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I miss the "Hey; I had this cool case the other day" threads. Granted, I hadn't had one myself in a while. Here's a beauty:

48 y/old female presents with generalized fatigue and weakness x2 days, and 1 day of jaundice. She states "I'm really not this color, usually." She is of southeast asian descent. She admits to mild DOE and mild dizziness upon changes in position. She states that she had a lithotripsy for a large ureterolith 4 days ago, done at the same facility, and reports no complications from the procedure. She is pleasant and cooperative in the exam room, accompanied by her sister. The patient is noticably jaundiced, with scleral icterus. Review of systems is completely negative.


Go.

 

[link2swim06]

What did her LFTs look like?

Did she accidentally OD on tylenol or something?

 

[RustedFox]

How about more H&P, first:

PMHx: HTN, Kidney stones
SurgHx: Lithotripsy, T/A as a child.
Meds: HCTZ, placed on pyridium and unknown antibiotic after lithotripsy as preventative measure
SocHx: Doesn't smoke. Doesn't drink. Doesn't do drugs. Doesn't lke rock n' roll. Married w/ 2 kids.
NKDFA.

 

[osumd]

has she been urinating? What color is it? Has she been taking the pyridium- it can do this, especially with problems clearing it from stones or what not

Any pertinent physical exam findings aside from the yellow skin & eyes? Any rashes or itching?

renal panel
LFTs to r/o antibiotic hepatotoxicity

 

[Groove]

Let's start with a set of vitals.

Anything else from the history? Recent travel back to Asia? Anything else on the Exam? Asterixis? Any neuro findings?

I love these.

 

[RustedFox]

Vitals stable as a rock.

HR = 68 and steady. BP = whatever, it never matters anyway. Temp = normal. Resp = 20 (because that's the only number that nursing knows).
SaO2 = LoLZ.

No recent travel back to Asia. This gal works at the hospital "down the street", but came here because "it would take me 50+ minutes to be seen over at Dickhead Medical Center."

Physical Exam:

GEN: Short, fat asian lady. Not "American!!" fat, but overweight.
HEENT: Icertic. EMOI. PERRL. LOLZ.
CHEST: WNL
ABD: WNL. No guarding/rebound/rigidity. Nontender in all quadrants. No HSM. BS+ x4. Normoactive.
EXTR: GTFO.
NEURO: Better than you.
SKIN: Yellow. School-bus yellow. Clearly out of proportion to her sister, who is sitting next to her.

 

[tele turnin]

Couldn't resist:

 

[Groove]

cbc,lfts,chem8,ua,ekg,cxr

Hx of G6PD?

 

[deleted547339]

Lithotripsy also break up her underlying gallstones which are now small enough to migrate down the GB neck into the biliary tree?

 

[deleted128562]

SE Asian descent so I'll say Thalessemia, probably alpha and probably minor, and the meds "tipped her over the threshold" due to increased hemolysis or something. Weakness/ fatigue can be a sympton of thalessemia and the rest of the picture seems to fit.

 

[ORL10]

I'd like direct and indirect bili with LDH and haptoglobin for 500 (after you give the basic chemistries of course.) I feel like urologists love bactrim and pyridium and that combo with G6PD could be in the answer.

 

[RustedFox]

CBC: Hgb: 8.7. WBC: 8.8. Plt. 230. Hct: LOLZ.
BMP: WNL
T.Bili: 9.3
D.Bili: 1.1
HFTs: WNL

Didn't get CXR, EKG, or haptoglobin. CBC/diff came back with remark of: "Many Schistocytes"

Going to theatre tonight, will have to pick this up tomorrow morning.

 

[inmyslumber]

I like the hat tip to Sir Arthur Conan Doyle and use of alliteration. However, Chinese is not equivalent to South East Asian.

Resume case discussion...now.

 

[RustedFox]

I like the hat tip to Sir Arthur Conan Doyle and use of alliteration. However, Chinese is not equivalent to South East Asian.

Resume case discussion...now.

Fine, dick.... 🙂 (just kidding) - gal is Taiwanese, which belongs to China, and is certainly in Southeast Asia. I have a Taiwanese goddaughter (and before some other forum-members jump on me for use of the word 'god' and my ostensible history on this forum... I refer to her as my 'spiritual advisee'), and her parents (whom I have been dear friends with since residency) would let us know that SE Asia is a big mezclado melting pot like any other.

 

[inmyslumber]

Taiwan is East Asian and/or Chinese depending on your politics. I only object to the "South East" reference in the original post.

Not trying to be a jerk, just trying to right (what I think are) wrongs. Apologies for the thread derail.

 

[Arcan57]

CBC: Hgb: 8.7. WBC: 8.8. Plt. 230. Hct: LOLZ.
BMP: WNL
T.Bili: 9.3
D.Bili: 1.1
HFTs: WNL

Didn't get CXR, EKG, or haptoglobin. CBC/diff came back with remark of: "Many Schistocytes"

Going to theatre tonight, will have to pick this up tomorrow morning.

What did the rest of the hemolysis labs look like? This doesn't smell like TTP due to nl BMP, lack of neuro findings, and a reasonable platelet count but I'd like to at least see an LDH and consider having pathology or heme look at the slide if there's any gray area. As noted, pyridium can cause jaundice as can Bactrim with G6PD deficiency. Are there any pre-op labs to compare the current CBC with? Was the spleen big (if so, kudos for being able to feel it on an overweight person)? What's her MCV and RDW (sorry, wife's a hematologist)?

 

[RustedFox]

Taiwan is East Asian and/or Chinese depending on your politics. I only object to the "South East" reference in the original post.

Not trying to be a jerk, just trying to right (what I think are) wrongs. Apologies for the thread derail.

Educate me. I gotta admit, I've got a broad brush that I'm painting with. Go on, and don't fear flaming or forum-fight. Its nuances like this that end up teaching us all something, and giving us all a good chuckle.

Anyways, - ballet was pretty cool. Back to the game.

UA: Heavy (spec.grav=wowzers), and full of bili.

Pre-op note has a HGB of 12.8

Anyways. I asked the gal: "Do any of your family members have any blood or hemoglobin disorders?" She spat right out: "Oh! All my cousins have alpha-thal, but I don't."