Re: Interesting cases

[Guest guest]

Consider hemachromatosis in Case #1- 30% may have hypogonadism and is associated with myalgias/myositis on occasion. Fatigue is one of the most common presenting symptoms. Assume the other labs that look great include thyroid studies, FSH, LH, prolactin? Re: case #2, anxiety playing any role? I have these folks eliminate wheat and dairy from diet. I'm finding some celiac negative patients are still benefiting from elimination of wheat. Many will prefer the idea of going "Paleo" rather than eliminating certain foods- same change for them but more palatable somehow per their mindset. Start probiotics. I'm careful with fiber - some don't tolerate it well. On occasion I've used the naturopathic concept of adding betaine HCL or apple cider vinegar

pre-meal. If IBS-type symptoms are persisting, consider FODMAP diet. And if diarrhea is truly frequent, would you consider colonoscopy for random biopsies to r/o microscopic colitis? And though its a stretch and likely not related to the diarrhea, I would assess for cannabinoid hyperemesis syndrome or a mild variant thereof... another possibility would be constipation with "diarrhea" being overflow which could account for all symptoms and be worse post cholecystectomy. Any history of toilet plugging stools as a kid? I do a basic KUB and ask radiology to comment on stool pattern. again- these people often benefit from eliminating wheat and diary (my current favorite recommendation).Carla Gibson FNP

To: Sent: Thursday, May 10, 2012 10:38 PM Subject: Interesting cases

I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.Case #2 is 20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on the

fly and can

get more specific about lab results.Thoughts??Thank you to the collective brain!!!Dannielle Harwood, MD

[Guest guest]

Case #1 agree with the previous postsCase #2—Consider ruling out porphyria (should be a genetic link). Also, consider hyperparathyroidism (stones, moans, abdominal groans)—is serum calcium normal From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 11, 2012 12:38 AMTo: Subject: Interesting cases I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.Case #2 is 20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on the fly and can get more specific about lab results.Thoughts??Thank you to the collective brain!!!Dannielle Harwood, MD

[Guest guest]

Interesting the v. low cholesterols,,, quick search showed these potential reasons, http://en.wikipedia.org/wiki/Hypocholesterolemia  It is ass. with higher morbidity/mortality.

His testost. is prob. low cuz on the low cholesterol as cholesterol is a hormone building block. Really high CK,,, It would be nice to know the causes, but pregnenolone supp might help raise cholesterol and testost. and that could only help.  Is he a vegan?

 let us know what you come up with, Anne

 

I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!

Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.

Case #2 is  20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.

Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on  the fly and can

get more specific about lab results.Thoughts??Thank you to the collective brain!!!Dannielle Harwood, MD

-- Anne Walch, MHS, PA-CHealing Path Integrative Medicinewww.hpimed.com

[Guest guest]

Get a good dietary history on both and consider eating disorder behavior or exercise addiction?The second case has labs that are similar to those in my low body mass anorexic/bulimic folks. Here is a great link to questionnaire that I find helpful. http://www.eat-26.com/ Let us know.Ramona From: [mailto: ] On Behalf Of Anne WalchSent: Friday, May 11, 2012 9:18 AMTo: Subject: Re: Interesting cases Interesting the v. low cholesterols,,, quick search showed these potential reasons, http://en.wikipedia.org/wiki/Hypocholesterolemia It is ass. with higher morbidity/mortality.His testost. is prob. low cuz on the low cholesterol as cholesterol is a hormone building block. Really high CK,,, It would be nice to know the causes, but pregnenolone supp might help raise cholesterol and testost. and that could only help. Is he a vegan? let us know what you come up with, Anne I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.Case #2 is 20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on the fly and can get more specific about lab results.Thoughts??Thank you to the collective brain!!!Dannielle Harwood, MD-- Anne Walch, MHS, PA-CHealing Path Integrative Medicinewww.hpimed.com

[Guest guest]

On case #1...definetely no exogenous steroids as this would disqualify him from competitions.

Is there a threshold for CPK or it there is no heme in the urine the kidney's are ok?

On case #2...his TSH cam back slightly elevated as well althugh reflex t4 is fine. Will check t3 at next visit.

Thanks for the insights so far.

Dannielle

Subject: RE: Interesting casesTo: Date: Friday, May 11, 2012, 10:49 AM

Case #1 agree with the previous posts

Case #2—Consider ruling out porphyria (should be a genetic link). Also, consider hyperparathyroidism (stones, moans, abdominal groans)—is serum calcium normal

From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Friday, May 11, 2012 12:38 AMTo: Subject: Interesting cases

I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.Case #2 is 20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on the fly and can get more specific about lab

results.Thoughts??Thank you to the collective brain!!!Dannielle Harwood, MD

[Guest guest]

Carla,

Did not do FSH, LH but may go back and do them as well.

On case # 2. I did a gastric emptying study which was nml but he complained of horrble cramping pain as soon as he drank the contrast for the study.

I do think he has some anxiety issues although at this point some of the anxiety revolves around the pain he gets after eating. He see a chiropractor who has him on some enzymes as ell as has done some eleimination diets with him in the past. He self reports that heavy meats like steak are espcailly bothersome.

Subject: Re: Interesting casesTo: " " < >Date: Friday, May 11, 2012, 6:54 AM

Consider hemachromatosis in Case #1- 30% may have hypogonadism and is associated with myalgias/myositis on occasion. Fatigue is one of the most common presenting symptoms. Assume the other labs that look great include thyroid studies, FSH, LH, prolactin?

Re: case #2, anxiety playing any role? I have these folks eliminate wheat and dairy from diet. I'm finding some celiac negative patients are still benefiting from elimination of wheat. Many will prefer the idea of going "Paleo" rather than eliminating certain foods- same change for them but more palatable somehow per their mindset. Start probiotics. I'm careful with fiber - some don't tolerate it well. On occasion I've used the naturopathic concept of adding betaine HCL or apple cider vinegar pre-meal. If IBS-type symptoms are persisting, consider FODMAP diet. And if diarrhea is truly frequent, would you consider colonoscopy for random biopsies to r/o microscopic colitis? And though its a stretch and likely not related to the diarrhea, I would assess for cannabinoid hyperemesis syndrome or a mild variant thereof... another possibility would be constipation with "diarrhea" being overflow which could account for all

symptoms and be worse post cholecystectomy. Any history of toilet plugging stools as a kid? I do a basic KUB and ask radiology to comment on stool pattern. again- these people often benefit from eliminating wheat and diary (my current favorite recommendation).

Carla Gibson FNP

To: Sent: Thursday, May 10, 2012 10:38 PMSubject: Interesting cases

I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.Case #2 is 20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on the fly and can get more specific about lab results.Thoughts??Thank you to the

collective brain!!!Dannielle Harwood, MD

[Guest guest]

I know when my Crohn's disease was really active my cholesterol was

also under 100 total, for several years. Now I am at like 150 with an

HDL of 70 (go fish oil). I also remember the feeling when barium hit

the inflamed area, extremely painful. Keep in mind that cholesterol is

made in the liver, excreted into the bile, then reabsorbed in the small

intestine. If you have absorption issues, it is not well absorbed.

Also keep in mind that some with IBD have only intermittent elevations

in there sed rate. Once you get a scarring in the intestine you have

poor absorption there but it may not be inflamed any longer. It took

forever for me to be diagnosed (5 partial obstructions) partly because

my Sed rate was normal. I probably now think everyone has Crohns, but

just a thought. Kris

Interesting cases

 

I am always interested in thoughts from the group collective brain..it

is so much larger and more experienced than my own!!

Case # 1 23 y/o male who is professional athlete complaining of fatigue

and low libido

CK is over 1000...at what point do I get concerned and tell him to

decrease or stop workouts?? His testosterone is low nml. Why??

Otherwise labs look great. Chol is barely 100.

Case #2 is  20 y/o college athlete with a 4 year history of abdominal

cramping, frequent diarrhea and sometimes vomiting or urge to vomit

after eating. Did have his GB removed because of single large stone 6

months ago.

Total chol is 92. Albumin is nml but globulin is low. WBC;s are

slightly low. Bilirubim is slightly elevated at 1.6

Has been tested for parasites, infection and celiac's.

I am writing this on  the fly and can get more specific about lab

results.

Thoughts??

Thank you to the collective brain!!!

Dannielle Harwood, MD

[Guest guest]

Agree.

I think it is not qualitative but quantitative with many disease processes.

We also rely too much on lab tests to confirm diagnosis. We need to use our

brains some more, and out labs a bit less.

I believe everyone is gluten sensitive, just to a different degree.

You also don't wake up one morning and presto you are Diabetic. It is an ongoing

metabolic issue worsened by poor diet.

Steve

stown, NJ

>

>

>

> Subject: Re: Interesting cases

> To: " "

> < >

> Date: Friday, May 11, 2012, 6:54 AM

>

>

>  

>

> Consider hemachromatosis in Case #1- 30% may have hypogonadism and is

> associated with myalgias/myositis on occasion. Fatigue is one of the

> most common presenting symptoms. Assume the other labs that look great

> include thyroid studies, FSH, LH, prolactin?

>

>

>

> Re: case #2,  anxiety playing any role? I have these folks eliminate

> wheat and dairy from diet. I'm finding some celiac negative patients

> are still benefiting from elimination of wheat.  Many will prefer the

> idea of going " Paleo " rather than eliminating certain foods- same

> change for them but more palatable somehow per their mindset.  Start

> probiotics. I'm careful with fiber - some don't tolerate it well.  On

> occasion I've used the naturopathic concept of adding betaine HCL or

> apple cider vinegar pre-meal. If IBS-type symptoms are persisting,

> consider FODMAP diet. And if diarrhea is truly frequent, would you

> consider colonoscopy for random biopsies to r/o microscopic colitis?

> And though its a stretch and likely not related to the diarrhea, I

> would assess for cannabinoid hyperemesis syndrome or a mild variant

> thereof... another possibility would be constipation with " diarrhea "

> being overflow which could account for all symptoms and be worse post

> cholecystectomy. Any history of toilet plugging stools as a kid? I do a

> basic KUB and ask radiology to comment on stool pattern. again- these

> people often benefit from eliminating wheat and diary (my current

> favorite recommendation).

>

>

> Carla Gibson FNP

>

>

>

>

>

> ------------------------------------------------------------

>

> To:

> Sent: Thursday, May 10, 2012 10:38 PM

> Subject: Interesting cases

>

>

>

>  

>

> I am always interested in thoughts from the group collective brain..it

> is so much larger and more experienced than my own!!

>

> Case # 1 23 y/o male who is professional athlete complaining of fatigue

> and low libido

> CK is over 1000...at what point do I get concerned and tell him to

> decrease or stop workouts?? His testosterone is low nml. Why??

> Otherwise labs look great. Chol is barely 100.

>

>

> Case #2 is  20 y/o college athlete with a 4 year history of abdominal

> cramping, frequent diarrhea and sometimes vomiting or urge to vomit

> after eating. Did have his GB removed because of single large stone 6

> months ago.

> Total chol is 92. Albumin is nml but globulin is low. WBC;s are

> slightly low. Bilirubim is slightly elevated at 1.6

>

> Has been tested for parasites, infection and celiac's.

>

>

> I am writing this on  the fly and can get more specific about lab

> results.

>

> Thoughts??

>

> Thank you to the collective brain!!!

> Dannielle Harwood, MD

>

[Guest guest]

thank you for this input! Helpful!

Subject: Re: Interesting cases

To: " "

< >

Date: Friday, May 11, 2012, 6:54 AM

Consider hemachromatosis in Case #1- 30% may have hypogonadism and is

associated with myalgias/myositis on occasion. Fatigue is one of the

most common presenting symptoms. Assume the other labs that look great

include thyroid studies, FSH, LH, prolactin?

Re: case #2, anxiety playing any role? I have these folks eliminate

wheat and dairy from diet. I'm finding some celiac negative patients

are still benefiting from elimination of wheat. Many will prefer the

idea of going "Paleo" rather than eliminating certain foods- same

change for them but more palatable somehow per their mindset. Start

probiotics. I'm careful with fiber - some don't tolerate it well. On

occasion I've used the naturopathic concept of adding betaine HCL or

apple cider vinegar pre-meal. If IBS-type symptoms are persisting,

consider FODMAP diet. And if diarrhea is truly frequent, would you

consider colonoscopy for random biopsies to r/o microscopic colitis?

And though its a stretch and likely not related to the diarrhea, I

would assess for cannabinoid hyperemesis syndrome or a mild variant

thereof... another possibility would be constipation with "diarrhea"

being overflow which could account for all symptoms and be worse post

cholecystectomy. Any history of toilet plugging stools as a kid? I do a

basic KUB and ask radiology to comment on stool pattern. again- these

people often benefit from eliminating wheat and diary (my current

favorite recommendation).

Carla Gibson FNP

----------------------------------------------------------

To:

Sent: Thursday, May 10, 2012 10:38 PM

Subject: Interesting cases

I am always interested in thoughts from the group collective brain..it

is so much larger and more experienced than my own!!

Case # 1 23 y/o male who is professional athlete complaining of fatigue

and low libido

CK is over 1000...at what point do I get concerned and tell him to

decrease or stop workouts?? His testosterone is low nml. Why??

Otherwise labs look great. Chol is barely 100.

Case #2 is 20 y/o college athlete with a 4 year history of abdominal

cramping, frequent diarrhea and sometimes vomiting or urge to vomit

after eating. Did have his GB removed because of single large stone 6

months ago.

Total chol is 92. Albumin is nml but globulin is low. WBC;s are

slightly low. Bilirubim is slightly elevated at 1.6

Has been tested for parasites, infection and celiac's.

I am writing this on the fly and can get more specific about lab

results.

Thoughts??

Thank you to the collective brain!!!

Dannielle Harwood, MD

[Guest guest]

I had w 19 yo pt abdo pain. No fever dx w mediterranean fever. She is armenianSent from my iPhone

Carla,

Did not do FSH, LH but may go back and do them as well.

On case # 2. I did a gastric emptying study which was nml but he complained of horrble cramping pain as soon as he drank the contrast for the study.

I do think he has some anxiety issues although at this point some of the anxiety revolves around the pain he gets after eating. He see a chiropractor who has him on some enzymes as ell as has done some eleimination diets with him in the past. He self reports that heavy meats like steak are espcailly bothersome.

Subject: Re: Interesting casesTo: " " < >Date: Friday, May 11, 2012, 6:54 AM

Consider hemachromatosis in Case #1- 30% may have hypogonadism and is associated with myalgias/myositis on occasion. Fatigue is one of the most common presenting symptoms. Assume the other labs that look great include thyroid studies, FSH, LH, prolactin?

Re: case #2, anxiety playing any role? I have these folks eliminate wheat and dairy from diet. I'm finding some celiac negative patients are still benefiting from elimination of wheat. Many will prefer the idea of going "Paleo" rather than eliminating certain foods- same change for them but more palatable somehow per their mindset. Start probiotics. I'm careful with fiber - some don't tolerate it well. On occasion I've used the naturopathic concept of adding betaine HCL or apple cider vinegar pre-meal. If IBS-type symptoms are persisting, consider FODMAP diet. And if diarrhea is truly frequent, would you consider colonoscopy for random biopsies to r/o microscopic colitis? And though its a stretch and likely not related to the diarrhea, I would assess for cannabinoid hyperemesis syndrome or a mild variant thereof... another possibility would be constipation with "diarrhea" being overflow which could account for all

symptoms and be worse post cholecystectomy. Any history of toilet plugging stools as a kid? I do a basic KUB and ask radiology to comment on stool pattern. again- these people often benefit from eliminating wheat and diary (my current favorite recommendation).

Carla Gibson FNP

To: Sent: Thursday, May 10, 2012 10:38 PMSubject: Interesting cases

I am always interested in thoughts from the group collective brain..it is so much larger and more experienced than my own!!Case # 1 23 y/o male who is professional athlete complaining of fatigue and low libidoCK is over 1000...at what point do I get concerned and tell him to decrease or stop workouts?? His testosterone is low nml. Why?? Otherwise labs look great. Chol is barely 100.Case #2 is 20 y/o college athlete with a 4 year history of abdominal cramping, frequent diarrhea and sometimes vomiting or urge to vomit after eating. Did have his GB removed because of single large stone 6 months ago.Total chol is 92. Albumin is nml but globulin is low. WBC;s are slightly low. Bilirubim is slightly elevated at 1.6Has been tested for parasites, infection and celiac's.I am writing this on the fly and can get more specific about lab results.Thoughts??Thank you to the

collective brain!!!Dannielle Harwood, MD