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Re: Difficutl diagnostic challenge From: Henry Gregor (henrygregor@yahoo.com) Mon Sep 29 13:01:48 2008 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Cesar Molina: "Re: for El again, and the last time" Previous message: Dr Eberhard Lisse: "Re: 12 hour PROM and GBS" In reply to: Ronald Ainsworth MD: "Re: Difficutl diagnostic challenge" Next in thread: Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C.: "Re: Difficutl diagnostic challenge" Expelled it! ... once again, the list provides a good range of observations. .. will share info re fatty liver issues,possible evaluations, with patient and her primary doc.   Thanks to all who commented.   Hank --- On Tue, 9/23/08, Ronald Ainsworth MD <ainsron@sbcglobal.net> wrote: From: Ronald Ainsworth MD <ainsron@sbcglobal.net> Subject: Re: Difficutl diagnostic challenge To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net> Date: Tuesday, September 23, 2008, 10:10 PM I would agree with avoiding BCPs, although the liver problems are probably only associated with mestranol which is no longer used.  Consider Mirena?   From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Henry Gregor Sent: Monday, September 22, 2008 1:09 PM To: Multiple recipients of list OB-GYN-L Subject: Re: Difficutl diagnostic challenge   Tangential topic...35 yo G0, wishes to preserve fertility potential requests ocp's to control dysmenorrheic symptoms unresponsive to conservative analgesic mgt, gives hx of "chronic fatty liver ds"with chronically abnl liver enzymes, checked q 2 months by FP and gastro consultant...pt doesn't know her values, other that "they're always up". Am attempting to get more info...first impulse in to counsel against ocp use, and second impluse is to review issue of potential lifethreatening risks from acute fatty liver should she achieve conception. Listers, your thoughts? --- On Tue, 9/16/08, Lynn Montgomery <apgar10@thebirthcentermt.com> wrote: From: Lynn Montgomery <apgar10@thebirthcentermt.com> Subject: Re: Difficutl diagnostic challenge To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net> Date: Tuesday, September 16, 2008, 12:59 PM Would still consider TTP/HUS.  Early acute fatty liver (blood glucose ?).  By odds, still represents HELLP Syndrome – remember hoof beats equals horses not zebras…   -- Lynn D. Montgomery, M.D. Obstetrics & Gynecology, Maternal-Fetal Medicine The Birth Center/Rocky Mountain Women's Health 1211 S. Reserve St. Missoula, Montana , 59801 406-549-0978 fax 406-549-0987 e-mail: apgar10@thebirthcentermt.com From: ob-gyn-l@obgyn.net [mailto: ob-gyn-l@obgyn.net ] On Behalf Of Andrew Folley Sent: Tuesday, September 16, 2008 10:38 AM To: Multiple recipients of list OB-GYN-L Subject: Re: Difficutl diagnostic challenge   Tough case colleagues!   32 week WF admitted 5 days ago to hospital with fever 102 and generalized complaints of low pelvic pain cramping etc.  OB hx now at 32 weeks G2P1 with prior csection. Idiaopathic polyhydramnios. Labs totally confusing with elevated lfts, LDH up, platelets 100K falling to 65K over 72 hours.  24 hour proteinuria 900 mg.  Pretty straight forward for preeclampsia with HELLP But...   Patient give absolutely no history of anything of the least significance. No drugs, travel, toxin exposure, no one sick at home, no history of transfusions, hepatitis etc etc. Conplains of nausea and emiesis but has appetite.  No headaches or neuro symptoms.   Physical Exam repeatedly past 5 days shows  Normal BP.  Recurrent daily fevers 38.2 to 39.2    Generalized abdominal pain at rest with nausea and emesis.  Slight dyspnea (patient with mild asthma hx) lungs clear on exam.  Central obesity at about 300#.  Good urine output. reflexes normal. 1+ edema. Developed diffuse maculopapular rash past 24 hours. (This Maybe due to the one dose of Claforan which surgery gave her last night??)   Chest Xray normal. CAT Scan no sign of appendix, cholecystitis, abcess free fluid etc. WBC 3000 with initial left shift. Coags normal.  Bilirubin normal with mild to moderate elevation of LFTs. LDH elevated. Uric acid normal.  Platelets falling 100K to 60 K over 3 days.  WBC remains low at 3000 but seeing progressive left shift to 50% bands. (lymphs, monos and eosiophils normal) TORCH negative, HIV neg, Several studies pending ricketsia, listeria, coxsackie etc etc etc all pending.  Blood cultures neg.  Urine culture negative. 3 hour GTT normal.  900 mg protein in 24 hours with normal cratinine clearance.   Consultants:  Surgery give antibiotics make NPO and operate for something.  Infectious disease: No idea what source of infection but seems to be bacterial based on "bandemia" is and do not give antibiotics.  MFM this is not HELLP or preeclampsia do not deliver. Hematology not impressed agree with bandemia, platelets suppressed secondary to this. No evidence of TTP based on peripheral smear. OB Gyn  (me and partners) "let us know when you want us to cut her".   Plan give IV fluids and wait and watch.  No antibiotics no steroids etc.   Just cant seem to get a handle on this lady. Open to any suggestions or similar cases in the past from our vast esxperience as a group. Thanks andy     From: dr99645@yahoo.com e. See Now   Next message: Cesar Molina: "Re: for El again, and the last time" Previous message: Dr Eberhard Lisse: "Re: 12 hour PROM and GBS" In reply to: Ronald Ainsworth MD: "Re: Difficutl diagnostic challenge" Next in thread: Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C.: "Re: Difficutl diagnostic challenge"

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