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...amage. As seen by laboratory studies, AST/ALT are elevated into four digit values, both total and direct bilirubin are increased also. LDH is increased too. This confirms massive liver cells damage. Coagulation studies are abnormal and albumin is low due to decreased synthetic liver function. Bilirubin is spilling into urine as expected. Etiologies of intrinsic liver damage can be: - Viral: Hepatitis A, B, or C. Patient has no risk factors for B or C. Possibility of A is remote too because nobody else got sick in her family (husband especially would have been at the highest risk). Her symptoms were not extremely intense either. Other viruses such as CMV, EBV, etc are also possible, considering patient¡¦s history of immunosuppressive treatments. - Drug-induced: Patient has used Tylenol quite intensively, but stopped 4 months ago. Her daily doses were not in toxic range. Cumulative effect is possible, but why manifestations are so late? Xanax was used prior to onset of the problems. It is not really known to cause liver damage. Baclofen was started after onset of jaundice and is unlikely to have caused damage in this scenario. - Autoimmune: While patient has tested negative for autoimmune disease before, it is a possibilty considering her neurologic deficits never found a definite answer. - Parasites and other infectious etiologies (malaria, toxoplasmosis, babesiosis, etc) are unlikely given lack of exposure. Etiologies of liver damage resulting from obstruction can be: - Gallstones: Her symptoms are not typical for gallstones, yet her family history is positive. RUQ tenderness could be seen as a positive Murphy sign. While low on the list, it cannot be completely ruled out. - Cholangitis: Could be secondary to gall stone obstruction. Seems unlikely unless we can find definite obstruction. - Cholangiocarcinoma or other cancers such as pancreatic obstructing the common bile duct: would be a surprise, but can not be ignored completely. There was no weight loss and no exam findings to support this. P: Draw Hepatitis panel, including HAV total and Ig M antibodies, HBV surface Ag and Ab, core Ag and Ab, etc. and HCV Ab. Abdominal ultrasound to look for gallstones, liver masses, etc. Anti-microsomal Ab, ANA, anti-smooth muscle Ab and sed rate for autoimmune etiology. Follow CBC, LFTs, coags, electrolytes daily. 3. Hx chronic Tylenol use: while acetaminophen¡¦s contribution to clinical picture is unlikely given relatively remote history of use, it can not be completely ruled out and, therefore, should be kept in mind. 4. Microcytic anemia: A: Patient has decreased MCV, hematocrit and hemoglobin . This signifies microcytic anemia. Thrombocytosis goes along with this picture as a reactive change secondary to anemia. Possible etiologies of anemia are: - Iron deficiency: It is quite prevalent in menstruating females, though the patient has no significant history of increased menstrual blood loss. Lab values are consistent with it, but on the smear red blood cells do not appear hypochromic. Need iron studies. - Chronic disease: Because patient has been ill for a number of years, this etiology is quite possible, but expect normochromic normocytic cells on the smear. - Hemolysis: Because hemoglobin is seen spilling in urine, one has to think of hemolysis. Blood smear revealed, however, only occasional schistocytes. This can also be myoglobin spilling in urine due to muscle breaking down. - Hemoglobinopathies: Blood smear revealed excessive number of target cells, which can signify thalassemia minor. Patient has a paternal grandparent with Italian background. However, appearance of target cells can also be attributed to liver disease, especially if it is more chronic than apparent clinically. - G6-PD deficiency: There is no appropriate history. Manifestations would be expected earlier. - Lead poisoning: Patient did move into a new house last summer, but it is unlikely to have any lead based paint. Might need more history on this, but unlikely to be the cause. P: Iron studies, TIBC, ferritin. Consider hemoglobin electrophoresis, CPK and haptoglobin levels. Follow CBC. 5. Thrombocytosis: most likely a reactive change to her liver disease and/or her anemia. 6. Leukocytosis with left shift: A: Most likely represents the general state of liver inflammation and is a reaction to a milleau of inflammatory mediators floating in the blood stream. Can also be due to a systemic infection. P: Draw blood cultures. Follow CBC. 7. Hypertension: A: Patient reported that she is usually hypotensive. Increased BP may be attributed to stress of dealing with a new and unexpected illness. This may also represent sequallae of liver congestion (like in cirrhosis and blood shunting), which is not apparent at this time. Patient has a family history of hypertension. Alternatively, hypertension may have developed some time ago and had gone unnoticed for a while. P: Watch BP trend for now. If increasing, consider anti-hypertensive therapy. 8. Hx Lyme disease, treated with multiple antibiotics: This has been treated more than extensively. It is very unlikely to be active at this time. 9. Weight gain: Most likely due to treatments with steroids and limited activity due to blindness. No recent history of weight loss. 10. Hx Reynaud¡¦s: this has not been an issue for several years. 11. FH Gall Stones 12. FH colon cancer 13. FH hypertension 14. Kidney stones x 3, s/p lithotripsy 15. Sulfa drugs allergy Side notes: What a sad story I must say. While hepatitis picture is the main acute clinical issue, neurologic deficits are striking in a 32 year old. I was surprised that it took them five days to get to the hospital. I guess having been in the hospitals plenty, patient and her family are not eager to go for it again. Yet I felt they wanted to know the answers so bad. Admission to the hospital was handled quite well, I thought, except that it took 3 or 4 hours for patient to be actually moved from the ED to the floor after medicine team decided to admit her. However, patient and her mother stated quite clearly that the service they received was the best and attention to their situation was above their expectations. I guess they have a lot to compare this hospital to. In terms of their insurance, it approved the admission without any glitches. According to the patient and her family ¡V during last five years they never had trouble with the insurance despite countless admissions and tests. DAY 2 S: I saw patient only during morning hours. She reported feeling ¡§better¡¨ than yesterday. Her husband felt that her scleral icterus was slightly less, but skin was ¡§as yellow as the day before.¡¨ Patient was put on the diet of clears only and had IV running. She reported having an appetite today. No more nausea was experienced. Patient did not have a bowel movement since admission. She is producing urine of normal yellow color as per her husband. She was also able to walk around the room with guidance by her relatives. Everyone is anxiously awaiting answers to all patient¡¦s problems. O: BP 186/120, RR 18, T982 Physical exam was unchanged from day 1. Labs: 11.7 135 108 8 10.2 460 94 34.1 3.7 23 0.8 AST/ALT 1593/1105„^ Sed rate 42„^ Alk Phos 94 ANA, Blood cultures, Hepatitis panel pending LDH 331„^ Total Bili 10.9„^ Direct Bili 7.3„^ Radiology: Abdominal US is scheduled for later today. A&P: 1. Neurologic problems: neurology consult is still pending. Medicine resident thinks that neurologic issues and hepatitis might have some common underlying process. 2. Hepatitis: It seems to be slightly better today judging from LFTs and patient¡¦s appearance. Abdominal ultrasound may shed some additional light this afternoon. Hepatitis panel may take a few days to come back. Patient¡¦s sed rate was up, but in a non-specific zone. It seems that nobody thinks that etiology of the hepatitis is somehow medication related. Anti-smooth muscle Ab and anti-microsomal Ab will be drawn tomorrow. 3. Anemia: Both hemoglobin and hematocrit are lower today. I wonder if excess IV fluid is distorting the lab values. Iron studies will be drawn tomorrow. Hemolysis is still a possibility. Haptoglobin and CPK have been ordered. CPK can be up due to Hx of muscle spasms. 4. Hypertension: It has gotten worse. In the morning hours this was ignored by the team, but some form of anti-hypertension therapy must be started. Etiology? I still can not really say what was the baseline BP. Side notes: There was some confusion on part of the patient and especially her mother regarding how the care is coordinated. I think they are more focused on her neurologic problems (which is understandable) and see this hospitalization as an opportunity to be worked up by neurologists more than a need to take care of apparent hepatitis. Medicine attending spoke with the patient and family in my presence. He was very good at explaining what is the primary cause that got patient admitted and what is our focus is. GI and, possibly, ID consults will be requested. Patient and her family were quite satisfied with the plan. GI fellow saw patient before I left for SCP ¡V his thinking about hepatitis was not much different from above. Unfortunately, I could not accompany patient to ultrasound. It seems that initial plan for work up has been formulated, but the only comment I heard from residents about the case if all hypotheses were to fall through was ¡§It will be very interesting¡K¡¨ It will be, but I think we should think and discuss possibilities in advance. DAY 3 S: A lot of things happened since yesterday. Patient went for abdominal US and was found to have hepatomegaly and slightly heterogeneous liver (?fatty infiltrate). Patient¡¦s gallbladder was abnormal with echogenic material present (?calculus cholecystitis vs. tumor). Patient was seen by a surgical resident, who agreed with cholecystitis picture and suggested surgery for today. This was contradicted by an attending surgeon this morning: he did not believe it was a gall bladder causing all the problems. Patient was, nevertheless, put on NPO regimen and scheduled for HIDA scan to better define gallbladder disease if present. GI consult note signed by an attending yesterday agreed with gall stone picture. Patient felt hungry today again. She complained of the heartburn after surgeons started her on Unasyn (in case she indeed had cholecystitis plus she had a fever up to 101 toward the evening yesterday). She and her family were very concerned about a possibility of an operation. Someone also suggested a liver biopsy and they were not sure what it is for exactly. Patient remained very hypertensive yesterday and was put on Labetalol. Patient¡¦s urine was also collected for 24 hour sample to check for creatinine, protein, VMA and metanephrine. Neurology fellow saw the patient this morning and was awaiting attending to come by. Finally, patient¡¦s HIDA scan done in the late afternoon was unproductive as her liver was not very active in up-taking the ¡§fake¡¨ radioactive bilirubin. She will be rescanned again tomorrow morning. O: BP 162/94 HR 104, RR 22, T 1004, then 101 Physical exam is unchanged except that jaundice is more pronounced. Labs: 11.2„` 134 106 5„` 10 514„^ 99 31.9„` 3.8 22 0.9 MCV 76.6„` Fe 46 CK 17 TIBC 488 Haptoglobin 46„` Hep B and C panels - negative AST/ALT 1831/1103„^ Alk Phos 92 Autoimmune studies, HAV Ab- pending Total Bili 12.7„^ Direct Bili 8.0„^ LDH 387„^ A & P: 1. Jaundice/Hepatitis: Jaundice is getting worse, but at this point hepatitis B and C are ruled out. They were not high on the list anyway due to lack of risk factors. Gallstone disease seems unlikely because ultrasound did not reveal obstruction. Cystic duct obstruction or just cholecystitis will be expected to have elevated alk phos and are unlikely to cause such high AST and ALT. Again, since the patient has been immunocompromised before, she may have any viral or parasitic infection that will be hard to detect with Ab levels. Will check amylase and lipase to completely rule out pancreatic involvement and will await HIDA scan repeat. Liver biopsy must be seriously considered. 2. Anemia: Iron studies were negative, but ferritin levels mysteriously did not make it to the order sheet. Thus, anemia of chronic disease, at least as a baseline condition, can not be ruled out yet. Haptoglobin was low, suggesting hemolysis, but whether it is present indeed or haptoglobin is not being synthesized by the liver is hard to distinguish. CPK was normal and thus, there is no muscle damage. 3. Fever: I think it is due to inflammation in the liver. Patient is being treated with Unasyn (1.5gm IV Q6 hours) and that should provide protection against sepsis. Blood cultures are pending. Will check CXR. 4. Hypertension: etiology is unclear. 24 hr urine is being collected to check for metabolites of epinephrine. Will also check renin and aldosterone. Labetalol (50 mg BID) will be continued for now and dose titrated to achieve normotension as patient seems to respond to this drug. 5. Neurologic problems: I think attending should see the patient later today. I vote for MS. Side notes: Patient is holding up well, but they are a bit frustrated as no answer is given to them yet. Lots of tests are being ordered. I am unsure if I see a need for VMA and metanephrines (What? Pheochromocytoma?). On the other hand, important ferritin did not make it to the lab on the order sheet. Also consultants are a bit disorganized in a sense that GI people see patient, tell her almost nothing and do not write their note until 6 p.m. I am glad surgeons did not take the patient to the OR. I do not feel it is gallstones. HIDA scan was, thus, almost a predictable waste of resources. Radiologists may want to do MRI next, I guess. DAY 4 S: Patient feels the same today, but her jaundice is worse. Repeat HIDA scan essentially showed that liver is not uptaking the substrate well and no conclusions about patency of biliary tracts can be made. Spasms of common bile duct or intra-hepatic obstruction are still possibilities. Radiologists suggested MRI. On top of that, patient developed diarrhea last night. It was watery, pale and without blood. This was deemed to be due to Unasyn and it was discontinued. Her diarrhea improved this morning and stool sample was taken for C. dif, WBC, ova and parasites. Heartburn decreased after antibiotic was stopped. Neurology attending saw patient last night and felt she had MS. She did not tell this to the patient, though. She will return to review all records patient¡¦s mom has. Finally, toward the late afternoon, a conclusion was reached to do a liver biopsy tomorrow in leu of other less invasive diagnostic tools left. O: BP 170/110, HR 93, RR 20 T 998 Physical exam remains unchanged with increasing jaundice and mild RUQ tenderness. Labs: 11.3„` 135 107 5 9.8 543 100 32.6„` 3.8 22 0.8 MCV 79.1„` HAV Ig M and total Ab - negative RDW 20.8„^ Total Bili 14.4„^ PT 14.8„^ Direct Bili 9.4„^ INR 1.77„^ LDH 375„^ PTT 39.0„^ AST/ALT 1842/1117„^ Stool studies: no WBC by Wright stain Alk Phos 89 Blood cultures/Autoimmune studies - pending Amylase 48 24hr urine: V = 2050ml Lipase 10 Cr = 56mg/dl Cr 24 h = 1.15g/d Radiology: CXR ¡V negative HIDA scan ¡V cannot rule out ca or obstruction A & P: 1. Jaundice/Hepatitis: Jaundice is worse today again. All hepatitis studies were negative. Gall stones were not firmly ruled out, but unlikely. Will turn to the last resort ¡V biopsy ¡V tomorrow. NPO overnight. To be totally complete, will check RPR and HIV test. 2. Fever: gradually subsided today. No pneumonia by X-ray. Blood cultures are still pending. Consider urine culture. 3. Hypertension: will increase labetalol to 100 mg tid. Renin and aldosterone are still pending. 4. Diarrhea: most likely due to broad-spectrum antibiotic. Will wait for stool sample results because C. Dif is possible. 5. Anemia: It is pretty much the same today as far as lab values are concerned. Nobody seems to pay attention to it for now. Intern working on the case proposed to do Coomb¡¦s test and check DIC panel. 6. Neurologic problems: MS as per neurology. 7. Prophylaxis: Pepcid recommended by GI in addition to Maalenta for heartburn prophylaxis. Side notes: It is gotten more complicated. I felt bad for the patient needing to undergo such an invasive procedure. Because she is a Jehovah¡¦s witness, we had a long discussion defining the respect we would pay to patient beliefs of avoiding blood transfusions. We left them (patient and her family) assured that if there was a life threatening blood loss during the biopsy, we would try all available means to save her without using any blood products. They seemed satisfied. On the other hand, I must gripe about GI people, who were hard to track down to hear about what was their decision regarding liver biopsy. Another question is where are social workers as I saw no signs of them and patient told me that once or twice someone showed up to ask if they were satisfied with the hospital stay. Nurses are great, however. Very helpful, when asked about patient. DAY 5 S: Nothing new has happened overnight. Patient continued to feel relatively OK without worsening of any symptoms except for jaundice, which became more profound. She said she felt like having an appetite, but because of expected liver biopsy she was kept NPO. No more heartburn was experienced. Diarrhea stopped as well. Patient was anxious about biopsy procedure, which was to be done via trans-jugular approach to minimize bleeding risk. At the same time Doppler ultrasound of hepatic and portal veins was to be done as well. Both procedures are scheduled for the late afternoon. O: BP 160/110, RR 20, HR 92, T 992 Physical exam unchanged Labs: 11 11„` 537„^ 134 108 5 98 31.5„` 3.7 22 0.9 MCV 78„` PO4 2.6 RDW 21.1„^ Mg 1.9 AST/ALT 1771/1017„^ Ca (ionized) 1.17 Alk Phos 79 Fibrinogen 294 Total Bili 15.6„^ FDP <10 Direct Bili 10.0„^ LDH 343„^ Microsomal Ab 1.1 (nl) PT 15.3„^ ANA <1:32 (nl) INR 1.89„^ Renin 0.7(nl) PTT 39.6„^ 24 urine protein 492„^ A & P: 1. Jaundice/Hepatitis: awaiting liver biopsy to hopefully give an answer, but jaundice has worsened. Yet patient does not feel worse. Auto-immune tests are starting to come back negative. 2. Fever: none today. 3. Hypertension: slightly better today, but may need to titrate labetalol or add something else to it. Renin levels are normal and urine tests are not available yet. 4. Diarrhea: none today, but stool cultures are not back as of a.m. today. 5. Anemia: It¡¦s not DIC. Anemia has not worsened much. Hemolysis is still under consideration. Nobody really buys into thalassemia yet, but more attention was paid to my reports about patient¡¦s blood smear appearance. 6. Multiple sclerosis: this appears to be an ongoing diagnosis, even though neurologists have not come back to discuss old records yet. 7. Prohylaxis: Pepcid has been switched to Nizatidine (Pepcid is not on the formulary?!) Side notes: The liver biopsy was scheduled for so late that I never made to it. Attending tried to push it for earlier, but was unsuccessful. It is frustrating to see patient not getting better and we still do not know what is going on with her liver. I hope it is not cancer. I am also disappointed at the flow of lab results and archeological age of the computer system. Labs that take a few days to come back are put along with labs ordered on that day and it takes 20 scrolls through computer screens to see if a desired test is back or not. It is aggravating and saves little time to all. DAY 8 (plus updates on days 6 and 7) S: Obviously, a lot of things happened during the weekend. Patient had a liver biopsy done successfully and without major complications late evening Friday. Presumptive diagnosis was autoimmune hepatitis and prednisone was started. Final biopsy report should be available shortly. The day after procedure patient did not feel well because of stomach discomfort secondary to a lot of gas swallowed during the procedure. This resolved by Sunday. Then on Sunday patient had onset of muscle spasms that were similar to those episodes she had prior to admission. Flexeril and then Valium instead were prescribed, but did not seem to help much. Today she continued to experience spasms that would occur almost every time patient moves her body. They start on her left side, involving an arm and then a leg. This is followed by progression to her right side. Spasms last 20-25 seconds and are very uncomfortable. Neurology saw the patient and recommended Baclofen. Patient¡¦s jaundice peaked on Sunday and is less today. Her appetite has been good throughout these days. Additional history taking revealed that patient has never been anemic before and her MCV has been normal. She also was tick bitten about 9 years ago, but Lyme disease tests were negative back then. O: T 983, BP 116/82, HR 82, RR 20. Physical exam: less jaundiced and no RUQ tenderness. muscle spasms: flexion of the wrists and forearms; extension of the legs. otherwise unchanged. Labs: Day 6 - WBC 12, Hgb 10.7, Hct 31.1, Plt 542, RDW 21, MCV 78.2; RPR and HIV negative; stool sample studies all negative; PT 14.7, INR 1.74, PTT 36; Na 130, K 3.8, Cl 108, CO2 23, BUN 7, Cr 0.9, Gluc 114, Ca ion 1.22, Phosph 4.0, Mg 1.9; AST/ALT 1751/1024, Alk Phos 77, Lipase 8, Total bili 16.8, Direct bili 11.7, Albumin 2.3(low), LDH 296, Ferritin 96(nl). Day 7 ¡V WBC 10.6 with left shift, Hgb 11.0, Hct 31.9, Plt 512, MCV 77.5, RDW 20.4; PT 14.7, INR 1.74, PTT 33.3; Na 136, K 4.2, Cl 109, CO2 21, BUN 11, Cr 1.0, Glucose 118; Ca ion 1.22, Phosph 2.0, Mg 1.9; AST/ALT 1712/1027, Alk Phos 78, LDH 322, Total Bili 20.2, Direct Bili 12. Today ¡V 10.8„` 137 110 17 16.2„^ 456„^ 111 30.7„` 4.0 22 0.8 Neutrophils 13.2„^ Bands 24„^ MCV 77.9„` Ca ion 1.24 RDW 22.5„^ Mg 1.9 AST/ALT 1089/862„^ PO4 3.0 Total Bili 17.7„^ Direct Bili 11.8„^ Albumin 2.1„` LDH 224„^ Blood cultures from day 2 are negative Alk Phos 68 PT 14.4„^ Pending: transferrin, prealbumin, microsomal Ab INR 1.67„^ and liver c...