need advice again...please give input

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Specializes in Adult NP- post acute care.

Hello all,

It's me again, the newer NP stationed at the post acute care setting....Please have mercy on me, as I have another question and I need your advice!!!

A resident c/o fatigue so I ran CBC and BMP. Hbg dropeed 2.0 since transfer from hospital about 2 weeks ago. Occult blood was negative. Iron studies results were not significantly abnormal (I can't recall exact results off the top of my head but I reviewed w/ my collaborating doc and no new orders.) Pt continued to c/o fatigue and mentioned new c/o malaise & myalgia w/ bilateral joint pain to shoulders, elbows, and hips. I repeated the CBC and obtained CMP, Vit D, ESR, RA factor. Hbg result was same (I think 9.5), Vit D 16, RA factor WNL, ESR not significantly elevated. Most surprisingly was the Alk Phos level in 300s, AST & ALT elevated (both AST & ALT in 150s). Bili was not elevated. Resident is scheduled for discharge home this week.

I will consult w/ my collaborating doc, and I will provide lab results for f/u to PCP upon discharge from NH. What labs would you order next? Would you check for hepatitis or defer to PCP since she is getting d/c'd later this week? Should I order the HCV antibody test? Resident denied ETOH use, she is not jaundiced, no ascites, no abd pain/discomfort. Pt has a frail appearance and recent ankle fx s/p ORIF. I will start on Vit D & Ca replacement.

Please share your thoughts. Thanks again for your input. Hope you all have a great week :)

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Specializes in Nephrology, Cardiology, ER, ICU.

Was the ankle fx a result if significant trauma? Probably needs malignancy work up. S-pep, u-pep, abd ct, CXR.

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Is she on any statins? You might consider a med review with the pharmacist. New grad NP, so take my advice with a grain if salt.

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Sadiemae, Checking medications is a good recommendation. Especially if the patient was started on any new medications during recent hospitalization. I'm my patient population with such high doses of diuretics admin gout attacks/flare ups can be a problem among other meds ( just an example).

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Something is messing with her liver. Do a medication check and consult with your collaborating MD about a Hep panel also. What did her kidney function look like? Like previously stated, if she was started on a Statin recently I would check that. Is she on Tylenol? Furthermore I never met an alcoholic truly admit to ETOH use or abuse but those liver enzymes definitely should be looked into. I'm curious. Let us know what the plan was.

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Ohhhh her Alk phos is up too! That's not good either! I'd be definitely chatting away with the Collaborating MD. Keep us posted!

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Specializes in Adult NP- post acute care.

Thanks for the input. Consulted w/ collaborating doc. Statin was d/c'd & Hep B & C panel ordered- results still pending. Pt will be d/c'd home tomorrow. PCP to f/u on Friday & our labs will be faxed over for review. Ankle fx was from mechanical fall. I'm wondering about malignancy too Trauma. I'll review Hep panel w/ doc to see if he wants to try to extend her stay & do more work up (insurance permitting of course). So many complexities & so little time to address w/ short term stay for rehab. I hope she follows up w/ PCP after d/c. I hear you about reluctance to admit ETOH abuse reddgirl- definitely a consideration. Kidney function WNL. Thanks again. I Appreciate the dialogue :)

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Liver enzymes and alk phos can be elevated with fracture. Joint pain common with low Vit D. Thyroid ok? Overhydrated?

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Specializes in Adult Internal Medicine.

Are the liver panel changes new? INR normal? Anyone in the facility have HepA? Is the bike duct dilated? Any hepatomeagly in exam?

Looking at the meds is a good idea as well, and is always the first step.

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Specializes in Adult NP- post acute care.

To pt's knowledge she never had elevated liver panel labs. No previous work up (liver function) from the hospital was sent over. The elevations in Alk Phos, ALT & AST came at a surprise and the pt was d/c'd 4 days after receiving the lab results & I don't think I checked a PT/INR which I should have ordered. No one in the facility was reported +HepA but I will be on the look out. No hepatomegaly on exam, but pt did have a splenectomy approx. 15 yrs ago. She insisted that no previous alc abuse- only occasional glass of wine. Pt had scheduled appt w/ PCP day after d/c & labs were faxed over for review.

Her 10lb wt loss over the past month and frail stature w/ myalgia & chronic generalized pain makes me suspicious of malignancy. I hope that I'm wrong & I hope she followed up w/ the PCP.

Thanks for the input BostonFNP

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Specializes in Adult NP- post acute care.

Would Alk Phos be elevated in the 300s from a fx? I'm just wondering.... I'm not sure if I checked her thyroid to be honest, but good point. Na level was WNL, no s/sx overhydration. Thanks Teacher First

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Could be with a fracture or some underlying bone disease

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