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SIGNIFICANCE OF FIGURES IN PRIVATE PRACTICE
OP Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Many doctors frighten the relatives of jaundiced patients the moment they see a Serum Bilirubin figure of 10, 20 or 30 mg. It is very important to know that often patients with very high bilirubin are not serious enough and vice versa, a patient even with low bilirubin of 10-20 mg can die.
I am writing this article to give figures of certain tests which are not mentioned in the textbooks, which I and my colleagues have seen in their private practice.
1.The highest bilirubin observed was 92 mg (this patient did not die). In fact it was more than 100 mg% and the Lab was unable to measure with it exactly. Patient had acute viral hepatitis with G6PD deficiency induced haemolysis and renal failure. Patient recovered completely after 3 months of intensive treatment.
2.The doctors frighten the patient the moment they see a Hb of 4 or 5 gms. These patients certainly can develop cardiac failure, and may need a blood transfusion. What I want to stress is that I have often seen female patients walking in my clinic with Hb of 2 gms. One of my colleagues has seen a patient with Hb of 0.78 gms. Of course this is possible only in India because the Indian women get "acclimatised" to low levels of haemoglobin and keep on working exactly like COPD patients who get acclimatised to low SPO2 levels.
I have a patient who has been coming to me from a far suburb for symptoms of COPD with clinically marked cyanosis and SPO2 of 50%! The fact is that this patient refused to get admitted in the hospital and used to come by train with the help of 2-3 relations to my clinic, while an average patient of pneumonia or asthma with that reading of SPO2 will be dead.
3.SGPT levels : there are many patients of viral hepatitis who develop SGPT levels of 5-10,000 or more and we have seen readings of 30,000 units in patients who had paracetamol or "yellow phosphorus" "(rat poison) poisoning". Very high levels of SGPT do not always indicate that the patient is going to have a fulminating course as massive necrosis of the liver. In fact, when the massive necrosis takes place the liver cannot manufacture SGPT and really speaking low level of SGPT will be seen. I have seen SGPT values of more than 20,000 units/ml in a patient of acute hepatic infarction. This patient had polyarteritis nodosa and succumbed due to multi organ infarctions.
4.LDH levels rise very high with massive haemolysis and can go upto 20,000 units. LDH levels are also very high in ischaemic injury to the liver.
5.Ferritin levels in the blood can increase due to reaction to an infection like ESR and C Reactive Protein (acute surface reactant).
In fact, in KalaAzar, levels upto 5000 units may be witnessed.
6.ESR - Very often ESR reading of 160 or 170 is seen specially in patients with extra pulmonary tuberculosis or multiple myeloma like conditions, specially in HIV patients.
Next, we come to some significance of the readings. A slight rise in Prolactin levels is always interpreted by GPs as the cause of sex complaints. Remember that unless the prolactin level is more than 3 times the normal, it cannot cause any complaints (Serum prolactin rises with domperidone).
PSA is diagnostic of cancer of the prostate, but can be normal in a patient having this illness. More important is that any patient having BPH or prostatitis or who has had a rectal examination, can show high PSA (prostatic surface antigen). Therefore diagnosis of cancer cannot be pronounced unless the reading is more than 30 units.
Then there are certain readings, which, the doctors should note, are very dangerous, e.g. Serum Calcium of more than 15-16 mg or Serum Potassium more than 7.5 mg can cause sudden fatality. As against this, the blood uric levels of 6-8 mg have no meaning and should always be repeated in another laboratory.
Similarly we have seen Serum Triglycerides with a level ranging from 5-10, 000 mg and Serum Cholesterol to 10,000 mg but in cases of familial hypercholesterolaemia the usual alcoholics, diabetics and fat businessmen and executives, the levels are usually less than 400 mg of blood cholesterol and less than 1000 mg of Serum Triglycerides. The triglyceride readings will be very high in heavy alcoholics and severe diabetics. Seen a child with Recurrent Pancreatitis and Sr. Triglycerides of 12,000.
Serum Amylase can be elevated to 10,000 units in case of severe acute haemorrhagic pancreatitis. Very high amylase levels have been seen in patients with pancreatic fistulas which have been in lakh’s in serous fluids and upto 20,000 in serum.
It is interesting to note that all these figures are not mentioned in the standard textbooks of medicine.
ACKNOWLEDGEMENT
I am very much thankful to Dr. Sunil Parekh, Dr. Sanjeev Amin and Dr. Deepak Amarapurkar for giving me their figures of private practice.
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