Liver

In a physician's toolbox, blood tests are obviously one of their primary weapons. 

In this particular patient, his or her stats were the following(please remember I always get permission from the patients.)

Patient believed he ate something bad. Patient presented acute onset of fatigue, nausea, but had no vomiting, diarrhea, abdominal pain, and fever. physical appearance was unremarkable except a look of acute fatigue. BT results showed:

bilirubin, total - 2.0

alkaline phosphatase, S(stands for serum) - 125

AST (SGOT) - 181

ALT (SGPT) - 197

Reference ranges as follows in the BT:

0.0-1.2

39-117

0-40

0-44

Now remember my mother has always emphasized the relative percentage from the baseline. Any person can see that this person's numbers are abnormal.

These blood test names correlate with liver function. These numbers indicate acute liver injury or parenchymal(meaning inside the tissue rather than an obstruction. Thus bilirubin and alkaline phosphatase numbers would be higher if there was an obstruction.) In the liver, these two items will be most likely elevated in the obstruction setting. 

US(ultrasound) confirmed no obstruction. Remember, I said relative, 2.0 to 1.2 and 125 to 117 is not that high.

Doctor started patient on an antibiotic for presumed bacterial gastroenteritis. After 1 tablet, the patient significantly improved. He or she felt much better. 

Conclusion? It could have been some acute food poisoning that affected his liver. The reason this is interesting is that most food poisonings do not affect the liver(particularly the liver enzymes.) Sometimes that is the problem with medicine, you might never know the problem but as long as the patient gets better, the end result is fine. Doctors need to be humble that they sometimes .cannot figure out everything - you just need to accept the result. Just be happy that the patient feels better.(It still bothers my mother as to what it was but she just golfs it off.)

Lucky Storm

Recently, the east coast had the storm of the century. By the way, if you ever live on a driveway, you should absolutely purchase a gas powered snow blower. It is one of the greatest inventions of all time and made my family's time in the snow a lot easier.

But one of my mother's patients had some complications during the storm.

Middle aged white male with a history of hypertension, hyper cholesterol, and was non compliant with medications. During the storm, the patient was shoveling the snow as most people were doing. After he had shoveled the snow, he experienced a sudden onset of severe upper back pain and had difficulty breathing.

He called 911 and they took him to the nearest ER. However, because of the storm the nearest ER was at capacity and they had to take him to the next nearest hospital. At the new hospital, the pt stated he was have severe back spasms but after examination, the doctors determined that he had an aortic aneuysm near the aortic arch and he needed to undergo urgent repair of his aorta. He underwent cardio thoracic surgery and his aorta was eventually repaired.

The luck came into the picture as if he had simply waited at the nearest ER, that facility was not equipped to handle a complicated procedure that the patient required. Thankfully, there were no complications and the patient fully recovered.

Missed time/hiatus

Been busy lately but I have many exciting cases that I will be posting. I also had to get some permission from a couple patient cases that I had forgotten but there are some really cool cases as well as some personal ones. Stay tuned!

Father's Eyes

My father has been experiencing quite a complicated case.

He has had underlying issues of diabetes and hyperthyroidism. Both conditions were intermittently under control.

Subsequently about 6 months prior, patient's eyes started tearing especially in windy conditions and increasingly in colder weather. Patient was also experiencing double vision in the periphery. Looking down and looking side.

At evening, difficulty driving as a result of double vision.

Patient went to the first ophthalmologist. Pt stated it was a very short office visit(first time visit) and stated it was rushed and ended in 15 minutes. Patient was told it was simply blephariitis and docotr said to sue baby shampoo(so the eyes won't tear) and wipe.

Patient then went to a second ophthalmologist. This physician was concerned about the underlying conditions of diabetes and hyperthyroidism. This doctor checked his eye pressure and there was borderline glaucoma, This physician was also concerned of my father's outward appearance of bluging eyes which can be indicative of Grave's disease(see earlier posts).

However, the patient continued to doctor hop as he wasn't receiving any effective treatment options. Pt then went to see a series of specialists including some of the leading ophthalmologist at JHU. The third ophthalmologist was able to explain his double vision. He had an orbital ultrasound test done that showed that there was hypertrophy his inferior and medial rectus muscles (there are six muscles in the eye that help you move around.) The double vision was the result of his eyes being misaligned from hypertrophy from those particular surrounding eye muscles.

The ophthalmologist concludes that the eye tearing is most liekly from inflammation which was blocking the tear ducts.(we have tear ducts that allow some tears to drain so we don't look like we're crying all the time.)

The best way to treat inflammation is through oral steroids. However problem with steroids is that it increase sugar level(which is a complication from diabetes) which can contribute to the glaucoma.

The ophthalmologist together with the endocrinologist that it would be take methylprenisode 16 mg bid.

PT was on new methyl-steroid significantly reduced tearing and with new prescription with new prism eyeglasses, pt has adjusted vision while it is early to tell he seems to be doing much better.

He will be having followups with ophthalmologist and glaucoma specialist and endocrinologist.


He was very frustrated that he had to see so many doctors. Some in the beginning where he felt that the physicians didn't really care about him. And I saw that it is so critical to make sure that the patient knows that the doctor cares about your problems. Obviously he had a very unique case with complicated underlying issues. But the doctor needs to make sure that the patient feels cared for and isn't just one appointment in a day of thirty.

Bad food

This case was a typical one but one that healthy middle aged woman.

After eating a hotdog and a pizza at a well known wholesale food court within one and a half hours, she developed severe abdominal cramps and profuse watery diarrhea. She also had nausea and vomiting for the rest of the day.

She was taken to the ER and was given a massive amount IV fluids and antiemetics(anti vomiting medication) and within two days she fully recovered.

What was the problem?

It was most likely staphylococcus aureus, which is an exotoxin related illness. Given that the patient's symptoms had a very acute onset within 3-6 hours after her meal and her very fast recovery.

Ramsay-Hunt Syndrome

Female middle aged woman with preceding flu like illness. She came in with acute onset of left ear pain. She developed some kind of tingling sensation on the right side of the face. She also complained of left ear tinnitus(ear ringing). 

Upon examination, she had left ear drum vesicular rash with some surrounding redness. 

The doctor narrowed it down to Ramsay-Hunt Syndrome caused by zoster virus. Patient was given short course of steroids and anti-viral medications and she completely recovered by follow up visit. 

Even if you're relatively young, you can still get the zoster virus!

ICD 9 to ICD 10 Transition

So I missed a couple of posts from some time off so forgive me.

This past month was very busy.

At the beginning of this month, there was the much heralded transition from the ICD 9 to ICD 10.

I'll give a brief summary again here. The CPT codes are the procedure codes that the physician checks off as he sees you. Depending on the complexity and time of the case, the physician has varying degrees of office codes in addition to any treatment codes such as vaccines, blood tests, or other procedures like EKG, etc.

Each of these CPT codes needs a corresponding ICD codes. These codes can ensure that the insurance companies can verify that these CPT codes or procedures were necessary as well as just having a documented recording of what was done.

The number of ICD 9 codes were 14,315 codes. ICD 10 will be bringing that number to more than 69,000 distinct codes.

Now why would they do this? I can list several reasons.

1. Not specific enough.

Some of the codes get very very specific. Down to the exact location. In the old ICD 9 codes some of the pain in XYZ place codes were very generic.

2. Reducing redundancy.

For example, vaccines had a CPT code and a corresponding ICD 9 code. Now they just have one vaccine code along with those CPT codes removing those ICD 9 codes.

However, there have been some transition troubles. With our EHR some of the codes we cant find on the system and our medical management software has some of them or doesn't have some of the codes. Some of the lab companies have had problems as well. We have a phlebotomist that can't find some of the ICD 10 codes that correspond with the ICD 9 codes. However, these are transition issues that I believe will resolve themselves over time as people adjust.