Stay Off the Admit Train

A man in his mid-50s with intermittent nosebleeds was sent in by his primary doctor for “abnormal labs.” The CBC sent from the office revealed a hemoglobin of 5.9 mg/dL. He had no past medical history and no sites of bleeding except for nosebleeds. Labs were sent to confirm the anemia as well as for potential admission.   His lab results were WBC 5.5; HGB 5.0; platelets 160; NA 124; K 3.4; Cl 99; CO2 23; BUN 16; Cr 1.8; glucose 71; anion gap 2; calcium 9.3; and albumin 2.1.   What is his diagnosis?   With the pressure on wait times and length of stay, I think much more often we put patients on the "admit train" to get them out of the ED. We put them in their "boxcar" with the hope that they will get off at the right stop. This patient was put on the severe anemia boxcar: Send appropriate labs, get consent for transfusion, admit, and move on. Seeing patients quickly is often given higher regard than taking the time to reflect critically on a patient's condition. A little more attention can make a difference in getting the patient on the best track.   Here is the biggest red flag. How often do you see a 50-year-old man with a hemoglobin of 5? How often do you see it in any man who doesn't have cancer, sickle cell, or a GI bleed? Um ... never. Sure, we see it all the time in women with heavy periods. A severely anemic male, however, is an anomaly worthy of deeper scrutiny.   The other unusual anomaly — an anion gap of 2. Recalling deeply ...
Source: Lions and Tigers and Bears - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs