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Puzzle: Help the Midwife (please!)

What does this picture show? I am still exploring myself, so any help is appreciated. The more complete the answer, the better.

- Causes (possible/probable)

- Treatments (herbal/homeopathic/allopathic/alternative/dietary/lifestyle)

- Immediate/Emergent Concerns (risks/hospitalization/lifestyle/etc.)

- Expected Course & Length of Treatment Before Recovery

- Are labs intertwined? Or are they a separate issue? What is happening with this woman?

Hx: 46 year old woman, G3 P3 hx extreme fatigue with unknown etiology. Labs drawn randomly found these values. Not on birth control. Does not have STD or any other chronic disease, but has recently recovered from a long-term chronic illness that included 3 years on a liver-toxic medication. Once the medication was stopped, her cholesterol shot up 400 points, a sign that the liver was having a stress reaction. It has since dropped 350 points in the last 9 months without medication (she refused to add any statins knowing it was a hyper-reaction to stopping the long-term liver-toxic medication despite being harangued to take them over and over). She is still on several medications that she is required to continue including Thyroid medications, Topamax, and minimal bipolar medications. All meds are stable, with the recent addition of a T3 (thyroid). Sx include constipation, extreme fatigue that does not resolve with any amount of sleep (even upwards of 16 hours a day) or the addition of hyper-caffeine/energy drinks, minimal urination despite copious amounts of water and iced tea (usually very watered down) each day. Also, she's 6 years post-Roux en Y Gastric Bypass (which must be taken into account with any iron supplementation). No dark stools, no dark urine.

Yeah, it's me.

TEST ABNORMAL RESULT Just in-range result Normal result NORMAL RANGE

Anemia Labs

Hgb 10.6 12.0-16.0 (6/18/07 11.1) (3/17/07 11.1) (12/14/06 11.8)

Hct 32.2 37-47% (6/18/07 32.6) (3/17/07 32.5) (12/14/06 35.1)

WBC 8.5 4.0-11.0 (6/18/07 6.6)

RBC 3.73 4.2-5.4mil/mm (6/18/07 3.59) (3/17/07 3.50) (12/14/06 3.77)

MCV 86.2 81-99 fL (6/18/07 90.6)

MCH 28.3 27-35 pg (6/18/07 30.8)

MCHC 32.9 32-37 g/dL (6/18/07 34.0)

RDW 13.9 11.5-14.5% (6/18/07 14.2)

Platelets 446 130-400(thous) (6/18/07 365)

MPV 8.3 7.4-10.4 fL (6/18/07 8.3)

Iron 33 60-170mcg

Iron Sat 8 20-50%

Ferritin 4.7 13-150ng/mL - (6/18/07 11.7)

TIBC 405 250-420mcg

B12 538 200-910 - (6/18/07 211)

Electrolyte Labs

Co2 23 21-32 (8/27/07)

Co2 15 21-32 (8/23/07)

Lactic Acid (serum) 21.5 5-20 (8/27/07)

Sodium 136 135-145

Creatinine 1.2 0.6-1.1

Okay, my lab sleuths... help me figure out what is going on, please. The abnormal labs have occurred extremely quickly (my last labs were done 6 weeks ago and looked nothing like this) and I have been feeling tired for years anyway due to varying illnesses, but have been absolutely extremely exhausted the past few weeks. The exhaustion crept up on me. I had no idea that I should tell anyone how ill I could be.

Ready, set, GO!

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Reader Comments (24)

What does your doctor say?

August 28, 2007 | Unregistered CommenterAlison Cummins

Wait a sec - um, see a doctor *today.* Sounds like it could be renal failure. (Low erythropoetin and wonky electrolytes, including creatinine.) You knew that, right? were just hoping it could be something else?

It could be of course, but it's worth seeing a doctor right now in case it is. An allopathic doctor.

Sorry. You don't need to be worrying about this.


August 28, 2007 | Unregistered CommenterAlison Cummins


If I had a diagnosis, I wouldn't be asking for help!

I have two separate docs that don't have the dedicated time I do to put to this puzzle. *I* am in charge of my own care. They are my assistants.

As my apprentice Donna taught me to say to clients:

Prenatal care is what YOU (the client) does between visits.

I already have begun tx for anemia and have eliminated ANY meds such as ibuprofin or Tylenol from my days (which weren't *too* often, but often enough) and have begun regular chiropractic again and serious visualizations of a beautifully filtering liver and now kidneys and my red blood cells growing and pulsating like a healthy and perfect heart.

Once I hear from either of the docs, I will let you know what they say. I got my labs on-line. Isn't on-line lab-getting the best now? I LOVE IT! No more waiting for a billion years for someone to call and tell you answers and scribbling down the numbers. Sheesh.

August 28, 2007 | Unregistered CommenterNavelgazing Midwife


No, I didn't know that. It's one of my suspicions. Why didn't she call me yesterday? Grrrr.

I'm peeing okay.

She said I might need to go in for blood gases. Wheee!

Okay, so what about the iron ones?

August 28, 2007 | Unregistered CommenterNavelgazing Midwife

OK, your ferretin is low, very, very low. If your iron has been low for a long time, the ferretin will be low - and so will myoglobin, usually - leading to muscle weakness, aka fatigue. Then you start looking at pernicious anemia (B12 deficiett90zncy), and other absorption/utilization problems.
If ferritin is A-OK, usually the source of tha anemia is something more acute. This has been going on for a while.
I am also concerned about kidneys.
Usually, kidneys that are failing will be dumping protein into the urine. Have you dipstick'ed lately? It's not diagnostic, you'd need a 24 hour urine + blood test at the same time to know for sure the GFR. But you could do it today. :)

August 28, 2007 | Unregistered CommenterJane

what is the MCV and MCHC.... the rest of those labs?

support your liver and adrenals --- things like st john'swort that rapid cycle certian things through the liver and have a mild ant- inflammatory effect as well as modulation of pain--

August 28, 2007 | Unregistered CommenterAnonymous

The kidneys filter waste from the blood. They also produce a hormone called erythropoietin that stimulates the bone marrow to produce red blood cells. If the kidneys are sick then they may not produce the hormone and your bone marrow will not know that it needs to make more red blood cells - even if your bone marrow is healthy and even if you have enough iron.

Because you have both strange electrolytes and anemia, I think about kidneys because they can have an effect on both. I'm not a medical person, I just have college biology, so I can't say more than that I have an index of suspicion.

Which is why the only advice I can give is... talk to a doctor!

More hugs!

August 28, 2007 | Unregistered CommenterAlison Cummins

The iron/anemia labs all indicate iron deficiency anemia, common with the malabsorption post gastric bypass. However, your TIBC is good.

The creatinine is a little high, but not alarmingly so.

Overall, with the extreme fatigue, my best (nursing) guess would be fatigue r/t anemia r/t malabsorption r/t post gastric bypass.

You need to be on a good iron supplement - one that won't aggravate your stomach pouch. Most likely a prescription iron supplement (I pick up mine today!).

Also - you need to rule out any GI bleeding, just to be on the safe side. Start with a stool specimen for occult blood.

August 28, 2007 | Unregistered CommenterAtYourCervix

Those aren't really complete labs for your particular situation. What about calcium? Potassium? (Parathyroid problem?) Urea?

What about your usual platelet count? What is your WHITE blood cell count - much more important with the platelets elevated and the symptoms.

Are you normally anemic? Ferritin low usually means iron deficiency. What about the *size* of the red cells (MCV etc)? If they're small, that's more toward iron, normal would be more like a bleed. High would be some other vitamin deficiency. Reticulocyte count? Is GI bleeding possible?

Whoa. Hope my curiosity doesn't mean I'm an internist at heart.

Let us know.

August 28, 2007 | Unregistered CommenterSara's Sad Alter Ego

Could there be occult bleeding somewhere?

Those electrolytes and decreased CO2 look like deyhdration.

I'd be thinking of an endoscopy to check out the bypass/pouch.


Probably not the cause, but if you are needing to add T3 you should look at whether you would be healthier on Armour. If you are not converting T4 to T3 then you are clearly not making enough T2. Then dose based on your Free T3 levels not your TSH.

Maureen (Mo)

August 28, 2007 | Unregistered CommenterAnonymous

I'm embarassed to say that biochem was never my forte' in nursing school. I hope you're able to figure out what's going on quickly and that it's not serious. Sending all my healthiest, happiest energy your way.

August 28, 2007 | Unregistered CommenterRed Pomegranate

You might want to check Melting Mama's site--she has a bunch of medical problems due to RNY WLS.


((((Hugs)))) I hope you find answers and feel better soon!

August 28, 2007 | Unregistered CommenterAngel

I second the kidney concerns. The creatinine isn't that high, but I think the fact that the liver is obviously compromised means that we can't go by creatinine alone as an indicator. What's your BUN (blood urea nitrogen)? If you're peeing more today, that's good. I'd imagine you might go for a creatinine clearance, the 24 hour pee test, as was suggested in an earlier post.

Thanks for all your wonderful words in your blog...I am a midwifery student who visits your site each day, thrilled to read of your life.


August 28, 2007 | Unregistered Commenterdenise

Just a guess, but it seems the most pressing issue is Anemia/Iron and perhaps some dehydration. While the Creatine is high, it's only a .1 I'd say find/fix the iron/anemia - try to keep hydrated and retest in 2-4 weeks.

And while kidneys can effect blood production, I'd think the Creatine/BUN would be much more dramatically off - and the RNY really makes me think Iron/b12/other mineral/vit absorbtion is the root problem....just my 2 cents - are you taking one of the prescription Iron supplements? I remember my Bro was taking a slow absorbing iron when he was on dialysis and having problems with aplastic anemia.

And right now it seems no matter how much we're drinking it's not enough It's too dang hot in East County!

So from a former exotic vet tech...if you were a monkey/gorilla/or chimp I'd be supplementing you for short gut syndrome (AKA RNY) hydration - keep you away from an alphas that were stressing you out..and retest....(and a few extra banana peels wouldn't hurt!)


August 28, 2007 | Unregistered CommenterOpening Pandora

So, I added a slew of the other labs for you great helpers. Thanks for caring and helping me. :)

I was able to add all the other abnormal labs I could access on-line until it had a hissy cow and shut me out. I really wanted a look at my other platelet results, but apparently, I was a tad too slow at it.

After poking around, I was FINALLY able to find this:


For those that won't be going there to read it, it speaks about Topamax and Hyperchloremic, non-anion gap, metabolic acidosis. The letter says in part, "...caused by renal bicarbonate loss due to the inhibitory effect of (Topamax) on carbonic anhydrase."

So, I've already lowered the Topamax by 100mg and will re-test in a couple of weeks and see if they need to be lowered more. I would CRAP to have to go off the meds, and luckily there seems to be a solution to not going off - and that's "alkali treatment" - whatever that is (I'll look it up later).

My doctor said my iron labs were worse than in the basement toilet and that it should be my full-time job to improve my iron levels. She said I should be better than my best client (she said "patient"). She said I will feel immensely better in 3-6 weeks, but it will take about 6 months of true, concerted effort to get myself to a place where I am not living in utter exhaustion.

She ordered a 24 hour creatinine. I will go pick up my lovely "vase" tomorrow.

I feel much better knowing what is going on. I really appreciate everyone's looking and helping me. It has helped me a lot.

And now, look! You all know my labs!

August 28, 2007 | Unregistered CommenterNavelgazing Midwife

See, I was wrong! (And I'm so glad.) That's why I stressed that while I might have a concern, I can't advise you to do anything except see a doctor.


August 29, 2007 | Unregistered CommenterAlison Cummins

Okay, so we've done occult blood (poop) - normal. No blood in the urine. It doesn't seem to be bleeding anywhere. Just regular ol' anemia. That's a good thing.

So, I'm on Floradix twice a day, alfalfa tablets (12 a day), 1000mg Vit C three times a day, eating the beef + all the other iron rich foods and snacks, added Omega 3 fish oil... gonna whip this into shape!

August 30, 2007 | Unregistered CommenterNavelgazing Midwife

the MCV being so big-- I say get some shots of B12-- and take sublingual folate---
sorry I saw your revision so late--

September 7, 2007 | Unregistered CommenterAnonymous

But, my B12 is great!

September 7, 2007 | Unregistered CommenterNavelgazing Midwife

I wonder about Topamax tie-in with anemia and thus exhaustion? I recently heard that people who take psychotrophic medications die an average of 25 years earlier than non-drugged folks. I will have to do some serious research to verify this, but if you read the literature by Robert Whitaker, of Mad in America, there is a profoundly compelling argument that these medications may, in many cases cause more harm than good

September 9, 2007 | Unregistered CommenterCaroline

Topamax isn't a psychotropic medication.

If I didn't take my psychotropic medications I wouldn't live to have 25 years taken off my life, so it's kind of a trade-off. A gamble I choose to take.

September 9, 2007 | Unregistered CommenterNavelgazing Midwife

serum B12 is meaningless--- you don't have clinical macrocytic anemia but it is borderline-- look at it-- coupled with the thyroid info-- plus folate and B12 will cover for eachother--- there is a hematology set of papers online- excellent stuff here--- look at the anemia info- or what ever else you might get some use of---


September 9, 2007 | Unregistered CommenterAnonymous

My eyes are getting blurry from all the numbers and latin names, so I'll be throwing in a crunchy suggestion - have you tried a liver flush?

December 5, 2007 | Unregistered CommenterDirty Harlot

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