A couple summers ago, I had this patient – lets call her Linda – a tired looking 62 year old lady whose very concerned son first brought her to ER after she had a syncope that morning as she was trying get off her bed. After 30 seconds she came around, was able to speak & slowly stand up with her son’s help.
In the ED, her vitals including a bedside glucose ( 5th Vital sign 😉!! ) were normal, she had no focal signs, denied any infection or chest symptoms or pain. She remembered feeling dizzy before and then waking up to her son’s concerned voice. Son denied any seizure movements in her. She takes Lopressor and HCTZ for hypertension, Metformin for Diabetes since 10 years, no change in doses. Labs were as follows:
Labs looked great, Later Troponin and EKG came back as normal too. Her recent heart screen was good a month ago. Because she was having some orthostatic symptoms since a week and a little nausea, dehydration was suspected, she was given a liter of IV NS bolus and sent home.Was asked to quit taking HCTZ and see her PCP for BP recheck in a week.
BUT …..Within 6 hours she was back in ther ER after a second syncope and was admitted to my service.
I went over her prior records and noticed that her Hemoglobin previous month during her heart screen was 16 ! going back at older records she has always been 15-16 range. When I asked her for history of black or bloody stools she revealed that had a couple really black stools within the last week before then normalized to brown and she didnt think much of it. When asked about NSAIDs, she states she takes Ibuprofen 3-4 times a week for monnths for general body aches.
And Bingo ! The culprit was acute blood loss anemia that was masquerading as normal hemoglobin in our EMR since her baseline was much higher. Also with nausea, eating/drinking less and taking a diuretic, we can expect some hemoconcentration from a little dehydration which contributes to a falsely elevated Hemoglobin. She underwent a EGD that showed a couple Duodenal ulcers, Positive for H.Pylori. She was discharged with high dose Protonix, H.Pylori treatment and advised to quit using NSAIDs.
Learning Tips:
- Hemoglobin should always be analysed in context of patient’s baseline levels!
- A GI bleed can be intermittent and easily forgotten or dismissed by patients as insignificant. You and I know black stools can mean a bleed – a lay person may not !
- It isn’t a patient’s job to tell us all symptoms, it is a clinicians job to ask for all applicable review of system questions and not miss anything
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