"I just put a young woman in her mid-30s back in room 9," the triage nurse said. I made a mental note that that was the GYN room. The nurse continued, "She feels bad, fatigued, and just not right in her stomach." The obvious question flew from my mouth. "Is she pregnant?"
"I have the urine, but the quality controls are being run now, so it will be a few minutes."
I glanced at the EMR before heading back to the room: normal vitals, no fever, no medications, a couple of kids, no surgeries, last period three weeks before. Not much there to go on, but I could see her while waiting for the urine.
I found a fully dressed young woman sitting comfortably on the bed. She gave me the same story. I thought I knew where we were going. I asked if she thought she was pregnant. The noncommittal answer made me sure I had the reason she was in my ED in the middle of the night. The answer would be in the urine.
Getting back to the computer, the urine results were back. Not pregnant!
OK, not the direction I thought we were going. Looking at the urine dip, which always seems to come in tandem with the urine pregnancy, showed she was not dehydrated and didn't have a UTI, but there was trace bilirubin and high urobilinogen. What to do with that?
She looked so good clinically. I could send LFTs to the lab. There goes the length of stay with an added hour at least to get the results back. Shared clinical decision-making! That would be the answer.
She wanted the tests. She felt bad. She wanted to know why.
I was shocked. She had hepatitis! I hadn't even truly considered that. She didn't look yellow, and I had been jaundiced that she looked too good to have anything seriously wrong. I was so sure of that that I wasn't swayed by the urine dip. How often do those abnormalities pan out?
Sometimes it is better to be lucky than good. She was diagnosed with acute hepatitis C. The HCV RNA PCR results were almost 2.5 million log IU/ml. Diagnosis on the first visit allowed for earlier evaluation, and likely prevented the spread of a communicable disease.
Looking back at this case, I am humbled. I anchored my diagnosis on pregnant or not. I even started to convince myself that the seen abnormalities were really red herrings leading me down a blind path. Yet these results are on a point-of-care dip because they can provide clues to a diagnosis. Bilirubin should not be in the urine. This patient's was only trace and may be a false-positive, but a high level of urobilinogen should also not be in the urine either. This combination should have significantly elevated the level of suspicion. Urobilinogen may be elevated with hemolytic anemias, hepatitis, and various toxicologic issues affecting the liver and causing cirrhosis.
Tip to Remember: High levels of urobilinogen are not normal, and should precipitate a work-up consideration of hemolytic anemia, abnormal liver issues, or both.