Would you do a tumor workup on this patient?

[coralfangs]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

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[Droopy Snoopy]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

wtf?

 

[BigRedBeta]

A TSH without other thyroid studies drawn at the same time are of extremely limited worth. You need to develop a better sense what constitutes a cost effective work-up.

 

[cpants]

Age, PMH, risk factors? Unexplained weight loss of 20 lbs in 2 months needs some kind of workup. Hyperthyroidism in light of her low TSH is the most likely explanation. Does she have any other signs or symptoms? Work it up. I would also do some basic tumor workup starting with a rectal exam, pap smear, cbc, mammogram, breast exam.

 

[SLUser11]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

Intentional 20 pound weight loss over 2-3 months, associated with exercise? AND she doesn't have slam-dunk, textbook hyperthyroidism?

I agree with you. This is cancer. I recommend an immediate exploratory laparotomy.

 

[Cruzinman]

Let's start with the basics. What is her chief complaint? Unexplained weight loss? If it's the designer jeans crowd, they usually brag about their weight loss rather than complain about it. I'd get a psych consult and think about anorexia nervosa. AN can also mess with your TFT's and would seem to fit this patient's lifestyle.

No charge for the consult.

 

[punkindrublic]

panscan with double contrast stat.

but seriously, if this is how present patients, please rotate with me.

 

[C5toC9]

the replies in this thread are hilarious

 

[jdh71]

Intentional 20 pound weight loss over 2-3 months, associated with exercise? AND she doesn't have slam-dunk, textbook hyperthyroidism?

I agree with you. This is cancer. I recommend an immediate exploratory laparotomy.

this post just dripped . . .

 

[jdh71]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

Why don't we get a free T4/T3 first here my friend? This could still be subclinical hyperthyroid.

And actually, yes, if a person was totally sedentary, they could conceivably lose 20 pounds with starting yoga and less calories.

 

[turkeyjerky]

panscan with double contrast stat.

but seriously, if this is how present patients, please rotate with me.

F that--we'd need triple contrast to really rule anything out

 

[cpants]

F that--we'd need triple contrast to really rule anything out

Yes, the enema is key. Probably should go for a PET scan and upper and lower endoscopy and cystoscopy too.

 

[fahimaz7]

Yes, the enema is key. Probably should go for a PET scan and upper and lower endoscopy and cystoscopy too.

I was gonna recommend a pelvic and breast exam while he's at it. Can never be too thorough.

 

[buckeye12]

I was gonna recommend a pelvic and breast exam while he's at it. Can never be too thorough.

And you can never go wrong with an ERCP.

Also, what the original poster forgot to tell us is that she's on levothyroxine and she's slightly over-medicated. And she weighed 173 pounds 2 months ago and recently began a strict Mediterranean diet, cut soft drinks out of her life, and started exercising for 30 minutes every day - and that 30 minutes was the P90X yoga routine.

 

[McGillGrad]

In the words of the great thespian, ARNOLD:

 

[Cruzinman]

Seriously speaking, when I was training, medicine was the cash cow that it no longer is. That was when they coined the phrase "million dollar workup", where we would literally order serum protoporphyrins in order to exclude acute intermittent porphyria in the differential diagnosis of the 150 or so causes of acute abdomen. The younger doctors seem to have more sensitivity to cost issues when ordering workups. Is cost consciousness this something they tech med students these days, or do you just get pick it up along rhe way like we did?

 

[McGillGrad]

Seriously speaking, when I was training, medicine was the cash cow that it no longer is. That was when they coined the phrase "million dollar workup", where we would literally order serum protoporphyrins in order to exclude acute intermittent porphyria in the differential diagnosis of the 150 or so causes of acute abdomen. The younger doctors seem to have more sensitivity to cost issues when ordering workups. Is cost consciousness this something they tech med students these days, or do you just get pick it up along rhe way like we did?

You quickly catch the drift after being constantly asked to clinically justify your labs by the lab techs, charge nurses and the radiologists.

Not that my residents mind justifying legitimate work-ups, but it makes it more difficult to follow hunches.

 

[Cruzinman]

Thanks, McGillGrad. I'll think twice next time before ordering a serum porcelein electrophoretic fractionation.

 

[cpants]

Seriously speaking, when I was training, medicine was the cash cow that it no longer is. That was when they coined the phrase "million dollar workup", where we would literally order serum protoporphyrins in order to exclude acute intermittent porphyria in the differential diagnosis of the 150 or so causes of acute abdomen. The younger doctors seem to have more sensitivity to cost issues when ordering workups. Is cost consciousness this something they tech med students these days, or do you just get pick it up along rhe way like we did?

At least where I train, most of the work is done in an inner city public hospital where the majority of patients are on charity care or the VA. Since each test hurts the hospital's bottom line (essentially goes unpaid for), from attending level down, each test must be indicated and justified. I think it makes sense, and not only from a financial standpoint. In almost all cases a million dollar workup doesn't help anyone except for the lab and radiologist. A stepwise and rational approach is safer, more effective, and cheaper.

 

[45408]

Seriously speaking, when I was training, medicine was the cash cow that it no longer is. That was when they coined the phrase "million dollar workup", where we would literally order serum protoporphyrins in order to exclude acute intermittent porphyria in the differential diagnosis of the 150 or so causes of acute abdomen. The younger doctors seem to have more sensitivity to cost issues when ordering workups. Is cost consciousness this something they tech med students these days, or do you just get pick it up along rhe way like we did?

Odds are good that the patient is on Medicare, and I'll be paying for those tests courtesy of my tax dollars. It's not like I get a commission on how many lab tests I order. Plus, I don't like writing down or remembering all of my patients' lab values, so unless there is an appropriate indication to get them, I don't.

But the medicine team who accepted a patient we had been consulted on apparently missed the memo. They ordered a complete metabolic panel on a patient on admission, as well as with morning labs. Of course, he was admitted around midnight, and they drew the labs around 1am, and the morning labs were drawn about 4 hours later. He was completely stable, and the first set of labs was stone-cold normal anyways. Way to go, guys.

 

[SouthernSurgeon]

Odds are good that the patient is on Medicare, and I'll be paying for those tests courtesy of my tax dollars. It's not like I get a commission on how many lab tests I order. Plus, I don't like writing down or remembering all of my patients' lab values, so unless there is an appropriate indication to get them, I don't.

But the medicine team who accepted a patient we had been consulted on apparently missed the memo. They ordered a complete metabolic panel on a patient on admission, as well as with morning labs. Of course, he was admitted around midnight, and they drew the labs around 1am, and the morning labs were drawn about 4 hours later. He was completely stable, and the first set of labs was stone-cold normal anyways. Way to go, guys.

Happens a lot at my hospital - a lot of the departments have developed automated order sets for admits that include daily lab draws.

 

[cpants]

Happens a lot at my hospital - a lot of the departments have developed automated order sets for admits that include daily lab draws.

The reflex AM lab order is pretty common. Luckily a BMP and CBC are pretty inexpensive, but I find it hard to believe that QAM labs improves outcomes over say Q3-4 days labs in the average patient. Would love to see some data on this if anyone knows of any. Obviously it's different if the patient has sepsis, requires transfusions, etc, etc.

 

[McGillGrad]

The reflex AM lab order is pretty common. Luckily a BMP and CBC are pretty inexpensive, but I find it hard to believe that QAM labs improves outcomes over say Q3-4 days labs in the average patient. Would love to see some data on this if anyone knows of any. Obviously it's different if the patient has sepsis, requires transfusions, etc, etc.

You solved your own quandary.

Many patients can go downhill pretty quickly, especially once they hit day 3-4.

 

[Cruzinman]

Thanks for all your comments. Now let me play the role of Ghost of Futures Past. Once you have been in practice a few years you will unlearn everything you've been taught in med school about critical selection of laboratory tests, and begin to practice the art of survival skills in our litigious society, otherwise known as defensive medicine. I know it sounds cynical, but because of fear of malpractice suits, when I order a battery of lab tests I do it half for the patient and half for the plaintiff's attorney who I may be someday facing in a courtroom. Specifically, in my community last year a plaintiff with a disabling periperal neuropathy was awarded a $ 1,000,000 judgement against a neurologist who failed to order serum B12 levels, this vitamin deficiency ultimately turning out to be the cause of the patient's illness. Even with the "community standards" defense (he practiced in an affluent community where one would not expect B12 deficiency) the doctor lost the case.

As a result you can bet your first paycheck that every neurologist who became aware of this case now orders B12 levels on all their PN workups, purely defensive, and of course driving up the cost of medical care.

 

[Depakote]

Thanks for all your comments. Now let me play the role of Ghost of Futures Past. Once you have been in practice a few years you will unlearn everything you've been taught in med school about critical selection of laboratory tests, and begin to practice the art of survival skills in our litigious society, otherwise known as defensive medicine. I know it sounds cynical, but because of fear of malpractice suits, when I order a battery of lab tests I do it half for the patient and half for the plaintiff's attorney who I may be someday facing in a courtroom. Specifically, in my community last year a plaintiff with a disabling periperal neuropathy was awarded a $ 1,000,000 judgement against a neurologist who failed to order serum B12 levels, this vitamin deficiency ultimately turning out to be the cause of the patient's illness. Even with the "community standards" defense (he practiced in an affluent community where one would not expect B12 deficiency) the doctor lost the case.

As a result you can bet your first paycheck that every neurologist who became aware of this case now orders B12 levels on all their PN workups, purely defensive, and of course driving up the cost of medical care.

because pernicious anemia isn't seen in affluent areas?

 

[mmmcdowe]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

This is a pretty prominent risk factor in endocrine tumors I hear.

 

[Cruzinman]

Depakote, good point. Just to be thorough, budding neurologists should also consider, in addition to ordering serum B12 levels on their PN patients also doing a wallet biopsy on their patients by co-ordering an ELISA assay for gastric parietal cell autoantibodies and F1Ab fragment assay for intrinsic factor blocking antibodies. Perhaps they might first spare their patients the cost by doing a CBC and checking for macrocytic RBC's.

 

[pianoman511]

Also something on the cheap side, were there any thyroid nodules palpated on exam ? If not, I would agree with the above posters about checking T3/T4 and maybe Anti-TPO Ab/antimicrosomal Abs.

 

[Cruzinman]

Pianoman, it looks like you've saved the toughest rotations for last, save Psych. We may not see you on these boards for awhile. Hang in there.

 

[45408]

Thanks for all your comments. Now let me play the role of Ghost of Futures Past. Once you have been in practice a few years you will unlearn everything you've been taught in med school about critical selection of laboratory tests, and begin to practice the art of survival skills in our litigious society, otherwise known as defensive medicine. I know it sounds cynical, but because of fear of malpractice suits, when I order a battery of lab tests I do it half for the patient and half for the plaintiff's attorney who I may be someday facing in a courtroom. Specifically, in my community last year a plaintiff with a disabling periperal neuropathy was awarded a $ 1,000,000 judgement against a neurologist who failed to order serum B12 levels, this vitamin deficiency ultimately turning out to be the cause of the patient's illness.

Of course, I can appreciate what you're saying, but your coin has two sides to it. You need plenty of rope, but you don't want to have enough rope to hang yourself. Many of these tests have risks and contraindications, and you could get yourself in trouble by ordering something that wasn't adequately indicated.

And I would feel guilty for trashing someone's kidneys with a load of contrast that was unnecessary. Or giving someone TRALI after giving them a transfusion that was marginally indicated.

You solved your own quandary.

Many patients can go downhill pretty quickly, especially once they hit day 3-4.

When that's the case, you usually have some other predictive indicators. You're not going to be diagnosing septic shock in a patient based on their WBC count. Plus, there's a difference between checking labs frequently on an unstable patient and checking them frequently on a stable patient.

 

[45408]

Intentional 20 pound weight loss over 2-3 months, associated with exercise? AND she doesn't have slam-dunk, textbook hyperthyroidism?

I agree with you. This is cancer. I recommend an immediate exploratory laparotomy.

But yeah, I'm with this guy...

 

[MLT2MT2DO]

Thanks for all your comments. Now let me play the role of Ghost of Futures Past. Once you have been in practice a few years you will unlearn everything you've been taught in med school about critical selection of laboratory tests, and begin to practice the art of survival skills in our litigious society, otherwise known as defensive medicine. I know it sounds cynical, but because of fear of malpractice suits, when I order a battery of lab tests I do it half for the patient and half for the plaintiff's attorney who I may be someday facing in a courtroom. Specifically, in my community last year a plaintiff with a disabling periperal neuropathy was awarded a $ 1,000,000 judgement against a neurologist who failed to order serum B12 levels, this vitamin deficiency ultimately turning out to be the cause of the patient's illness. Even with the "community standards" defense (he practiced in an affluent community where one would not expect B12 deficiency) the doctor lost the case.

As a result you can bet your first paycheck that every neurologist who became aware of this case now orders B12 levels on all their PN workups, purely defensive, and of course driving up the cost of medical care.

Kind of piggybacking off your previous post. Was the RBC morphology normocytic?

 

[McGillGrad]

Kind of piggybacking off your previous post. Was the RBC morphology normocytic?

What do you think? He/She was b12 deficient.

 

[McGillGrad]

When that's the case, you usually have some other predictive indicators. You're not going to be diagnosing septic shock in a patient based on their WBC count. Plus, there's a difference between checking labs frequently on an unstable patient and checking them frequently on a stable patient.

Yes, I understand what you're getting at because some people are checked every other day or what-have-you, but if they are ill enough to be admitted, it is probably a good idea to keep an eye on them...especially after the first 3-4 days thanks to your best friend, hospital acquired infection.

 

[Depakote]

What do you think? He/She was b12 deficient.

I think that's the point. Cruzinman is attempting to use this case to show how everyone is suddenly practicing defensive medicine b/c the doc didn't check B12 levels... but it seems like a patient with "disabling periperal neuropathy" should have gotten a screening CBC to check for macrocytosis as B12 deficiency seems to be a common enough cause that most 3rd year med students know to check for it. So either the test wasn't done or didn't lead them down the proper diagnostic pathway.

 

[45408]

Yes, I understand what you're getting at because some people are checked every other day or what-have-you, but if they are ill enough to be admitted, it is probably a good idea to keep an eye on them...especially after the first 3-4 days thanks to your best friend, hospital acquired infection.

It goes both ways. All the things we do to keep a closer eye on someone - a central line with CVP monitoring, a Foley for urine output, an art line for BP monitoring, etc. - can also cause more problems than they save. I'm in the hospital every day, but I don't get nosocomial infections. Keep your testing/diagnostics to an appropriate minimum, and you'll lower their risk.

The ICU Book says the average ICU patient has >100 lab tests done during their hospital stay, requiring 500cc of blood. Oh no, now they're anemic! Give them a transfusion! Oh no, now they have TRALI, consult pulmonary, heme/onc and cardiology!

 

[MLT2MT2DO]

I think that's the point. Cruzinman is attempting to use this case to show how everyone is suddenly practicing defensive medicine b/c the doc didn't check B12 levels... but it seems like a patient with "disabling periperal neuropathy" should have gotten a screening CBC to check for macrocytosis as B12 deficiency seems to be a common enough cause that most 3rd year med students know to check for it. So either the test wasn't done or didn't lead them down the proper diagnostic pathway.

This is what I was getting at, if the patient did have macrocytic anemia and a B12 wasn't done then is the outcome really that big of a suprise?

Now if the B12 deficiency was being compensated and the cells were normocytic or the hematology analyzer maybe doesn't have a sensitive enough RDW (maybe pt had iron def and B12 def, offsetting each other never warranting a morphology) then that makes his point of defensive medicine alot stronger.

 

[Cruzinman]

You all make excellent points. Unfortunately my scope of the case was limited to reading the legal opinion on the peripheral neuropathy. It didn't provide enough other clinical or lab data re macrocytosis. This may sound old fashioned, but we learned how to assess macrocytosis by the old fashion naked eye on a peripheral blood smear. We all wound up with hematomas on our fingertips from repeatedly lancing ourselves to obtain blood drops enough times to please our sadistic instructor that we could make the perfect "feathered edge". This probably sounds like ancient history since I assume that these days the lab uses flow cytometry to get the RBC indices and no one actually looks at a peripheral smear anymore. Nothing beats the naked eye. For example I can look at a blood smear and in five minutes pretty much predict that my patient has thrombocytopenia even before I get the platelet count back. And if I see bone marrow precursor cells on the blood film I'll have the hematology consult on the chart for a BM aspiration before the CBC results get back on the chart. Call me old fashioned but sometimes the naked eye beats the machine.

 

[MLT2MT2DO]

You all make excellent points. Unfortunately my scope of the case was limited to reading the legal opinion on the peripheral neuropathy. It didn't provide enough other clinical or lab data re macrocytosis. This may sound old fashioned, but we learned how to assess macrocytosis by the old fashion naked eye on a peripheral blood smear. We all wound up with hematomas on our fingertips from repeatedly lancing ourselves to obtain blood drops enough times to please our sadistic instructor that we could make the perfect "feathered edge". This probably sounds like ancient history since I assume that these days the lab uses flow cytometry to get the RBC indices and no one actually looks at a peripheral smear anymore. Nothing beats the naked eye. For example I can look at a blood smear and in five minutes pretty much predict that my patient has thrombocytopenia even before I get the platelet count back. And if I see bone marrow precursor cells on the blood film I'll have the hematology consult on the chart for a BM aspiration before the CBC results get back on the chart. Call me old fashioned but sometimes the naked eye beats the machine.

How the lab handles the CBC morphology is hospital dependant. Usually there are criteria that gets met on a, as you stated, machine that is normally operated per flow cytometery. From there if the MCV/RDW indicated a look at this slide it would then manually be confirmed.
Just like everyone else in the medical the lab is constantly inendated with samples. I agree that the naked eye beats the machine but it isn't always practical. I can run ~50 automated CBCs in the same amount of time it takes to make a sing smear, let it dry, stain it, let the stain dry, and manually record my results.
If you're in a field other than pathology or hem/onc and you are still able to differentiate alone myelocytic series, I commend you. Most providers I've ran into aren't able to do that.

 

[McGillGrad]

How the lab handles the CBC morphology is hospital dependant. Usually there are criteria that gets met on a, as you stated, machine that is normally operated per flow cytometery. From there if the MCV/RDW indicated a look at this slide it would then manually be confirmed.
Just like everyone else in the medical the lab is constantly inendated with samples. I agree that the naked eye beats the machine but it isn't always practical. I can run ~50 automated CBCs in the same amount of time it takes to make a sing smear, let it dry, stain it, let the stain dry, and manually record my results.
If you're in a field other than pathology or hem/onc and you are still able to differentiate your myelocytic series I commend you. Most providers I've ran into aren't able to do that.

I knew you were a lab rat from your first post...lol...

 

[Cruzinman]

Thanks MLT2. I didn't mean to imply that I can differentiate which myelocytic line a precursor cell came from on a peripheral smear. Only that I think that I can tell when there is a cell type on a smear that ought not to be there. I leave the rest to the hematopathologists.

 

[TMP-SMX]

I watched a pernicious anemia case on Mystery Diagnosis on Discovery health and a patient with disabling peripheral neuropathy and dorsal column symptoms had no anemia at all. Took a long time to diagnose. (Diagnosed by a rheumatologist of all people). Taking in plenty of folate (common with the fortified American diet) will mask the anemia, and this is an important point.

 

[Droopy Snoopy]

I watched a pernicious anemia case on Mystery Diagnosis on Discovery health and a patient with disabling peripheral neuropathy and dorsal column symptoms had no anemia at all. Took a long time to diagnose. (Diagnosed by a rheumatologist of all people). Taking in plenty of folate (common with the fortified American diet) will mask the anemia, and this is an important point.

I've watched like 6 of those Mystery Diagnosis shows in my life, and for whatever reason I think every one of them climaxed with a rheumatologist saving the day.

 

[VA Hopeful Dr]

I watched a pernicious anemia case on Mystery Diagnosis on Discovery health and a patient with disabling peripheral neuropathy and dorsal column symptoms had no anemia at all. Took a long time to diagnose. (Diagnosed by a rheumatologist of all people). Taking in plenty of folate (common with the fortified American diet) will mask the anemia, and this is an important point.

We had a grand rounds case yesterday about a woman with B12 deficiency who had completely normal CBC but fairly significant neuro symptoms, so you're quite right that lack of macrocytic anemia doesn't mean it can't be B12 related.

Also, folate will not only mask the anemia it tends to actually worsen the neuro symptoms.

 

[dienekes88]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

Did you do a physical exam?

How old is she?

What are her risk factors?

If I recall correctly, serum thyroglobulin should tell you if it's exogenous thyroid ingestion. Kinda like C-peptide in surreptitious insulin administration vs. insulinoma.

 

[jdh71]

Did you do a physical exam?

How old is she?

What are her risk factors?

If I recall correctly, serum thyroglobulin should tell you if it's exogenous thyroid ingestion. Kinda like C-peptide in surreptitious insulin administration vs. insulinoma.

 

[dienekes88]

hahaha. nice pic.

Def. didn't read the thread before posting.

 

[MedLover25]

She comes in with a weightloss of 20pounds since Oct for a normal physical exam. Checked her TSH, it was low. She denied taking any weightloss pills.
She's one of those upper class folks with designer jeans and handbags.
I still think she's been taking one of those thyroid-related weightloss pills and she thinks that her weightloss is totally normal.
No middleaged women can lose 20pounds just by doing yoga.

Of course I can check her i131 intake but would that cost a lot and don't think she would do it.

However, she didn't have the clear cut signs of hyperthryoidism

I think you're letting "weight loss in cancer" without realizing it's "unexplained" weight loss that is problematic. I could imagine you jumping to this conclusion if you're new to rotations and are fresh out of "being stuck in a classroom trying to learn this stuff" mindset.

If you presented the case as "A 54 year old woman presents with a 3 month history of unexplained weight loss. She has lost 20 lbs during this time with no increase in daily activity. No changes in diet. She is a 30 PY smoker. etc etc etc The physical exam was notable for R axillary lymphadenopathy - 3 cm, well circumscribed, nontender, fixed and bilateral groin lymphadenopathy, etc."