Case 6 (9/01/2013): Subsequent Patient Management
Click this link to download the case file from box.net:https://app.box.com/s/exokq95vd63ktbaylmxy
…Case 6 is a 22 year-old male who presents with sudden onset of intense jaundice. Fever, chills, myalgia, poor appetite and intermittent diarrhea developed one week prior to ER. He was treated by primary physician 2 days prior to ER for nasal stuffiness and post-nasal drip with oral Cefdinir and Zofran. You may assume that information not listed in the patient case sheet was either not recorded or not significant.
Objective Data (Review entire patient case sheet for complete information):
Row 13, 14: Hgb 13.9 gm/dL, MCV 96.1 fL, Total Bilirubin 36.0 mg/dL and Direct Bilirubin 27.6 mg/dL, 6:25 hours prior to admission.
Row 21 to 24: EBV VCA Early Ag, IgG and IgM positive; EBV Nuc Ag negative, 00:16 hours post-admission.
Row 25, 26: Hgb 11.2 gm/dL, MCV 91.7 fL, Total Bilirubin 35.3 mg/dL 3:24 hours post-admission.
Row 33, 34: Hgb 9.6 gm/dL, MCV 94.4 fL, Total Bilirubin 44.0 mg/dL, 26:16 hours post-admission.
Row 39 to 45: Reticulocyte Count 3.2% (90,000/uL), Haptoglobin 10 mg/dL, LD 1,080 IU/L, Ferritin 5,241 ng/mL, Iron 115, TIBC 270, 40:11 hours post-admission.
Row 48, 50: Hgb 8.3 gm/dL, MCV 93.3 fL, Total Bilirubin 40.1 mg/dL, 51:46 hours post-admission.
Row 56 to 61: Hgb 9.2 gm/dL, MCV 93.4 fL, Total Bilirubin 34.2 mg/dL, Reticulocyte Count 4.9% (140,000/uL), LD 842 IU/L, 75:16 hours post-admission.
Row 63: Hematology Consult, 80:12 hours post-admission: Direct Coombs negative, Indirect Coombs positive 1+; not hemolytic anemia; positive Monospot, likely acute EBV hepatitis
Row 70 to 74: Hgb 7.8 gm/dL, MCV 91.9 fL, Total Bilirubin 30.0, LDH 885 IU/L and Reticulocyte Count 8.4% (200,000/uL), 101:51 hours post-admission.
Row 78: Bone Marrow Aspiration, CT-guided, 108:43 hours post-admission: Hypercellular marrow with non-necrotizing granulomas; erythroid hyperplasia; M:E 4.5:1.
Row 84: PRBC transfusion, 1 unit, 114:42 hours post-admission.
Row 90: Hgb 8.4 gm/dL, MCV 95.0 fL, 124:51 hours post-admission.
Row 97: Total Bilirubin 11.6 mg/dL, 148:16 hours post-admission.
Row 104 to 107: Hgb 7.7 gm/dL, MCV 95.1, Reticulocyte Count 12.2 % (290,000/uL) and Total Bilirubin 7.1 mg/dL, 172:31 hours post-admission.
Row 112 to 115: Hgb 8.5 gm/dL, MCV 104.9, Total Bilirubin 5.4 mg/dL, LD 497 mg/dL
Row 119: Discharged, 201:11 hours post-admission (8.4 day Length of Stay)
Comment: You must download the file after opening the link in box.net, or you will not be able to easily see all of the information in the file. This discussion follows the initial patient presentation posted 9/01/2013 and gives members a chance to compare how they felt the patient should be managed with how the patient was actually managed. A commentary on the patient case management will be posted Friday. This material is Copyright © 2013 by Columbia Healthcare Analytics, Inc. and may not be used for other purpose without written permission.
Questions:
Is the data listed inconsistent in any way? What is your clinical assessment in this case? Does this patient require PRBC transfusion?