T1-2B CONSULTATION REASON FOR CONSULTATION: Dr. Alanda Asked Me to Me

Essay

T1-2B CONSULTATION
REASON FOR CONSULTATION: Dr. Alanda asked me to see the patient over concerns that she might have an autoimmune hemolytic anemia.
HISTORY: The patient is a 59-year-old female who has had a stormy course after open reduction internal fixation of a supracondylar fracture of her left femur. Postoperatively, she developed respiratory problems, ARDS (acute or adult respiratory distress syndrome), and also has been felt to have a cholestatic liver problem.
Chief problem is that her bilirubin is over 4. Her hemoglobin has failed below 7 g, and she has increased reticulocytes. She has been transfused recently several units and despite that her hemoglobin has dropped. Dr. Alanda was under the impression that her direct Coombs' test was positive but in checking into this further, her direct antiglobulin test was negative, but she did have multiple other alloantibodies.
In reviewing the chart, her past history is significant for coronary artery disease, obesity, hypertension, tobacco abuse, and hyperlipidemia. She had a right CVA (stroke/cardiovascular accident) with hemiparesis last year.
From the chart, I am not aware if she previously had blood transfusion.
MEDICATIONS: She is on a panoply of medications as listed in Dr. Naraquist's consultation notes.
ALLERGIES: None known.
SOCIAL HISTORY: No significant alcohol abuse, but a 2-pack-a-day smoker. She does not work outside the home.
FAMILY HISTORY: Her mother died of leukemia. Father died of congestive heart failure at age 58. A sister died at age 29 of a myocardial infarction.
REVIEW OF SYSTEMS: At this time is impossible as the patient is sedated on a ventilator and unresponsive to questions.
She has hepatitis serology and HIV (human immunodeficiency virus) serology pending at the time of this dictation. Clotting studies were negative. Her Coombs' test was negative as mentioned above and antibody screen was positive. Reticulocytes were done late last night and absolute reticulocyte count was 113,000. Recent troponin level was negative.
PHYSICAL EXAMINATION: The patient is moribund. She is obese. She is sedated at this time on a ventilator. Vital signs are being maintained within a reasonable range at this point. She is not grossly jaundiced. Lungs reveal diminished air entry. Heart tones are normal and regular. Her abdomen is massively obese. No definite liver or splenic enlargement. No external bruising noted. Sclerae may be slightly icteric. No lymphadenopathy. There is no gross edema appreciated in extremities. She has a Foley catheter in place and the urine from that is pink. Other formal testing was not possible because of the patient's condition.
I spent time looking at her peripheral smear. She does have enucleated red cells in the peripheral smear and a left shift. This is probably a leukoerythroblastic reaction related to some hemolysis and to her recent ARDS and surgical procedure. There are no increased numbers of spherocytes noted. There is significant polychromasia. Her liver functions were significantly abnormal with elevation of her hepatic enzymes and her bilirubin was as high as 9.6, but is down to 4. Almost all this bilirubin is direct reacting which would certainly be more consistent with hepatic disease on the face of hemolysis or excessive bleeding.
IMPRESSION:
1. Significant anemia, which probably is related to hemolysis. This, at least in part, is probably related to alloantibodies and engendered by her recent blood transfusion. She had no antibodies, probably a result of the transfusion and probably a result of previous exposure to blood transfusion. The elevated bilirubin is in part due to her hemolysis and in part due to impaired hepatic function. There is no evidence of autoimmune hemolytic anemia in her case.
2. ARDS (acute or adult respiratory distress syndrome).
3. Obesity.
In this situation, it would be critical to give plenty of IV (intravenous) fluids with appropriate diuresis to try and maintain adequate urine flow.
Thank you for this consultation.
T1-2B:
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