Q&A: Question to medical professionals ONLY. Looking for a second opinion?


by Rob!

Question by coolfloridian: Question to medical professionals ONLY. Looking for a second opinion?
23 y/o w/f with constant and severe abdominal pain usually in RUQ but sometimes radiates to the LUQ or LLQ, constant nausea, always cold, occasional vomiting, excessive weight gain (40 lbs—all weight loss efforts have been unsuccessful.)

Symptoms began (2 years ago) with bloating, gas and occasional diarrhea. Slowly over time symptoms increased to constant pain with alternating diarrhea and constipation. She was initially diagnosed with cholysistitis and had a cholysistectomy. A liver biopsy during the surgery showed a fattly liver. When the symptoms didn’t resolve, she was diagnosed with gastroparesis. The treatment for that isn’t working either. Recent labs showed mild hyperlipidemia and mildly elevated liver enzymes. Celiac disease and ulderative colitis have been ruled out. Parasites have been ruled out. We cannot seem to find a diagnosis and therefore she does not have a treatment plan.

My question to professionals ONLY: Do you have a suggested diagnosis that I can take to her doctors? They are out of ideas too.

Best answer:

Answer by Ryan
How do you someone is a medical professional on here? How do you know I’m not a cat? In all seriousness, it’d be much more difficult to diagnose you than a doctor with access to an examination and history of you.

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Comments

Q&A: Question to medical professionals ONLY. Looking for a second opinion? — 1 Comment

  1. “My question to professionals ONLY: Do you have a suggested diagnosis that I can take to her doctors? They are out of ideas too.” — Well, I’m a health care provider and I make my living at it so that makes me a professional. But you cannot, absolutely cannot, get a diagnosis online, without being examined and probably not without diagnostics of some kind and you cannot, cannot, cannot be diagnosed by anyone who is not an NP, PA or MD. As well, without a comprehensive health history to review (her chart), some things have to be guessed at and that’s not how I prefer to work. You’ve described some things but I don’t have vital signs, an op report, a path report, imaging reports, labs or progress notes to look at. Having said this, what I can do is offer some ideas, observations and/or suggestions and I think this is what you’re looking for.

    “When the symptoms didn’t resolve, she was diagnosed with gastroparesis.” — Gastroparesis? Not with weight gain. That’s not consistent with gastroparesis.

    “The treatment for that isn’t working either.” — Then, logically, that’s because she doesn’t have gastroparesis.

    ” She was initially diagnosed with cholysistitis and had a cholysistectomy.” — Did she have the diagnostic tests used to diagnose cholecystitis? Was a more conservative treatment approach taken or even discussed before the “choley” (cholecystectomy) was done? It may be that her gallbladder was fine. What was the pathology on it?

    “A liver biopsy during the surgery showed a fattly liver.” — Which type of fatty liver disease? It makes a difference. Was it NAFLD (nonalcoholic fatty liver disease), FLD (fatty liver disease), nonalcoholic steatorrhoeic hepatitis, or alcoholic hepatitis?

    ” Recent labs showed mild hyperlipidemia and mildly elevated liver enzymes.” — The elevated lipids come as no great surprise nor do the liver enzymes. My guess is that her AST and ALT were elevated, since these are the most commonly affected. She may also have had her ALP levels evaluated.

    If anyone taking a closer look at this woman’s liver?? AST is aspartate aminotransferase, ALT is alanine aminotransferase, ALP is alkaline phosphatase and all are enzymes mainly found in the liver but also in other organs and tissue. When hepatocytes (liver cells) contain these enzymes and when hepatocytes are damaged or destroyed, their cell wall is breached and these enzymes spill out and are released into the blood. The higher the enzyme levels, the more cells that are involved. And the more cells that are involved, the greater the damage.

    ” We cannot seem to find a diagnosis and therefore she does not have a treatment plan.” — I’m glad the rule outs were done. Has this young woman been evaluated yet for metabolic disorders/disease?

    There are so many causes of elevated enzymes, abdominal pain (in any 1, 2 3 or all 4 quadrants), nausea et al. I suppose, if you have time and inclination, you could try cross referencing her symptoms. List the causes of each symptom in separate columns. Causes of elevated liver enzymes in one column, causes of hyperlipidemia in another column and so on. Then see what condition (or conditions) show up in multiple columns. The ones that show up in the most categories may be conditions to pay closer attention to and this is essentially how a differential diagnosis is made.

    Lyle, if you’re a fellow nurse, I apologize for “speaking” as if to a patient. You know we’re obligate teachers. But try the metabolic angle, friend.

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