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MORNING

Tim Ohlsen REPORT


11/28/2018
A CASE…

• A 2 month old boy comes into your office for well child check and…

Actually me
A CASE…

• A 2 month old boy comes into your office for well child check and…

Yep, that’s
jaundice

Look at that jaundice!


TIME FOR QUESTIONS
Weight: 50.4% | Height: 49.7% | OFC: 44%
Afebrile, vitals normal

Gen: Awake and alert, well-appearing


HEENT: AFOF, +cradle cap, +posterior plagiocephaly,
+scleral icterus
CV: RRR, Normal S1/S2, no m/r/g, good pulses EXAM
Resp: Normal effort, CTAB
Abd: Normal bowel sounds, soft, NTND, no HSM
GU: Normal
Skin: Jaundiced to abdomen
Neuro: Appropriate, good tone, tracking well
Hepatic/Cholestatic Hematologic Endocrine/Metabolic
Infectious hepatitis RBC membrane Hypothyroid
Alagille Syndrome defects Hypopituitarism
Biliary Atresia RBC enzyme Galactosemia
deficiency (G6PD)
Choledochal Cyst Drugs/toxins
Hemoglobinopathy
Other Biliary Metabolic disorder
Obstruction Autoimmune hemolytic NOS
anemia
Rotor Syndrome
DIC
Dubin-Johnson Other
Syndrome Breastmilk jaundice
DIFFERENTIAL Alpha-1 antitrypsin Cystic fibrosis
CHF
Poor conjugation TORCH infection
Gilbert Syndrome Carotenemia?
Crigler-Najjar
Syndrome
DIAGNOSTIC ALGORITHM

QUESTIONS TO ANSWER QUESTIONS ANSWERED

• Is this sepsis? • No
• Is this an obstructive (cholestatic) • Fractionated bilirubin, CMP
process?
• CBC and reticulocyte count
• Is this a hematologic process?
Hepatic/Cholestatic Hematologic Endocrine/Metabolic
Infectious hepatitis RBC membrane Hypothyroid
Alagille Syndrome defects Hypopituitarism
Biliary Atresia RBC enzyme Galactosemia
deficiency (G6PD)
Choledochal Cyst Drugs/toxins
Hemoglobinopathy
Other Biliary Metabolic disorder
Obstruction Autoimmune NOS
hemolytic anemia
Rotor Syndrome
DIC
Dubin-Johnson Other
DIFFERENTIAL Syndrome Breastmilk jaundice
Alpha-1 antitrypsin Cystic fibrosis
CHF
Poor conjugation TORCH infection
Gilbert Syndrome Carotenemia?
Crigler-Najjar
Syndrome
Direct Indirect Either
hyperbilirubinemia hyperbilirubinemia Hypothyroid
Alagille Syndrome RBC membrane defects Hypopituitarism
Biliary Atresia RBC enzyme deficiency Galactosemia
Choledochal Cyst (G6PD)
Metabolic disorder NOS
Other Biliary Obstruction Hemoglobinopathy
TORCH infection
Autoimmune hemolytic
anemia
Infectious hepatitis (None)
DIC
Alpha-1 antitrypsin Carotenemia
DIFFERENTIAL Gilbert Syndrome
Rotor Syndrome
Crigler-Najjar Syndrome
Dubin-Johnson
Syndrome
Drugs/toxins
Cystic fibrosis Sepsis
CHF Breastmilk jaundice
(FIRST PASS) WORKUP

• CMP/gGTP
• CBC/smear
• Retic count
• TSH!
• Check newborn screen
• +/- Coombs, LDH/hapto, TORCH, urine
reducing substances, A1AT, sepsis workup
LABS

CMP CBC/Retic Other:


Lytes: normal WBC: 3.4 (L), ?ANC 700 TSH: 2.9
Glucose: normal Hb: 10.7 DAT (days later): negative
AST 70 Hct: 30.6 LDH/Haptoglobin (later):
ALT 30 Plt: 319 boring
Total Bili 11.0 RBC: 3.6 Repeat smear (later): boring?
Direct Bili 0.5 MCV: 85.5 Repeat bili: 5.7
Albumin 3.9 MCHC: 35.0 G6PD: normal
GGTP: Normal RDW: 13.8
Retic Hb: 30.6 (high 35.5)
Retic %: 1.4 (high 1.5%)
Smear: 1+ schistocytes, 2+
tear drop cells
AN UNFULFILLING END
QUESTIONS