“Let’s play…doctor” – diagnosising

I are going to go through some of the steps a doctor could take to arrive at a diagnosis.  ***Disclaimer and apology to all my terrific friends who are also physicians: Please know that the following is said with tongue in cheek as I do know that this is oversimplification of all that goes into making sound medical decisions, not to mention the years of education and experience, but this is just for easy reading.                                                                Now that you have put on your white lab coat, your day starts off with “rounds” (this is where you get a report on the patient). Wayne, our patient, presents with a hemoglobin of 6.7.  He was last transfused 2 days ago.  He has elevated LDH (717), decreased haptoglobin, elevated bilirubin, Coombs test is positive.    Off you trot into the room, of course, only after you stop to put on your protective clothing.  Yes, you see for yourself, indeed the patient has jaundice, his appearance supports the likelihood of malnourishment even though he has generalized edema, and the patient is complaining of being tired. “Ah-ha: you, the reader, are saying,some of this has already been in the blog, so I can piece this together”.                                                                                                                               • Wayne has had nutritional supplementation and is now on a low microbial diet with additional supplements. Thus, his overall nutritional status is improving.                               • Edema: abnormal accumulation of fluid in the interstitium, which are locations beneath the skin or in one or more cavities of the body. It is clinically shown as swelling for which Wayne is being given diuretics (lots of going potty), he is loosing water weight and is improving. His extremities, back, abdomen and face are not as puffy and swollen. Still difficult to assess healthy weight gain given fluid but appearance indicates improvement.           •  Hemoglobin normal range for adult male is 14-18gm/dl.  (So you, the reader, may not have remembered the exact value for the hemaglobin – but you know it’s low.)                    • Continued need for blood transfusions – bone marrow functioning but cannot keep up with demand.                                                                                                                           • Jaundice: the yellow color of skin, mucous membranes and eyes when there are excess levels of bilirubin in the blood                                                                                                  •  Bilirubin – the yellow chemical in hemoglobin, the substance that carries oxygen in your red blood cells.  RBC’s are broken down and then processed by the liver. With accelerated destruction of RBC’s, hemolyosis, the liver cannot handle the volume of blood cells as they break down, bilirubin builds up in the body and skin may look yellow.            • Hemolyosis- the premature rupture or breaking down of the RBC’s.                                 • Coombs test positive:  A positive Coombs test indicates that an immune mechanism is attacking the patient’s own RBC’s.                                                                                     We haven’t talked about this one but it is helpful for you to know,  as this is a lab test often run if you are having any heart damage, muscle damage or such:                                        • LDH (lactate dehydrogenase) – Normal LDH levels range from 140 units per liter (U/L) to 330 U/L  and becomes elevated in response to cell damage. LDH is abundant in red blood cells and can function as a marker for hemolyosis.                                                              By now, some of you may have guessed, yes I have given hints, and of course there are some real smarty pants out there, but for the rest of us playing doctor we say “Hmmm” …., I think I can guess at the reason for his jaundice and fatigue, but I don’t know why this all happening”. So like many doctors you do the first thing that comes to mind, order additional labs to see what up!  

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