Instructions
You are a medical student on placement in the maternity assessment unit. Liezel Reyes, 29, is 35 weeks and 2 days pregnant with her first baby and has been admitted with four days of vomiting and upper abdominal pain.
Interpret the results provided
Outline to the examiner:
- Your interpretation of the results
- Your most likely diagnosis and differentials
- You do not need to take a history or examine the patient
- The examiner will ask you one question at the end
Admission note
Four days of nausea and vomiting; nothing kept down since yesterday. Two days of upper abdominal pain, worst under the right ribs. Very thirsty; drinking and passing a lot of water. Tired, off her food. No itch, headache, visual change or swelling. Baby moving; no bleeding, leaking or tightenings.
Antenatal record
G1 P0, dated by a 12-week scan. Booking BP 112/70. Booking bloods normal; hepatitis B, hepatitis C and HIV negative. Normal 20-week morphology scan; glucose tolerance test at 26 weeks normal. Antenatal multivitamin; paracetamol 1 g twice a day for two days. No allergies. No travel this year.
Admission bloods and urine (today)
| Item | Value | Reference range |
|---|---|---|
| Haemoglobin | 112 g/L | 110-150 g/L |
| White cell count | 18.0 x10^9/L | 5.0-15.0 x10^9/L |
| Platelets | 110 x10^9/L | 150-400 x10^9/L |
| Blood film | Neutrophilia; no fragmented red cells | - |
| INR | 1.9 | 0.9-1.2 |
| APTT | 44 s | 25-38 s |
| Fibrinogen | 1.2 g/L | 4.0-6.0 g/L |
| Sodium | 136 mmol/L | 135-145 mmol/L |
| Potassium | 4.4 mmol/L | 3.5-5.2 mmol/L |
| Urea | 9.6 mmol/L | 2.0-5.0 mmol/L |
| Creatinine | 165 umol/L | 40-70 umol/L |
| Urate | 0.62 mmol/L | 0.15-0.40 mmol/L |
| Glucose (random) | 2.8 mmol/L | 3.5-7.8 mmol/L |
| Bilirubin (total) | 92 umol/L | <20 umol/L |
| Bilirubin (conjugated) | 68 umol/L | <5 umol/L |
| ALT | 420 U/L | <35 U/L |
| AST | 380 U/L | <35 U/L |
| ALP | 380 U/L | 30-250 U/L |
| LDH | 410 U/L | 120-250 U/L |
| Ammonia | 78 umol/L | <50 umol/L |
| Bile acids (random) | 18 umol/L | <10 umol/L |
| Urine protein (dipstick) | Trace | Negative |
| Urine ketones (dipstick) | 3+ | Negative |
Hepatitis A, B, C and E serology: pending.
Ultrasound of the liver and fetus (today)
| Item | Value | Reference range |
|---|---|---|
| Liver | Normal size; diffusely increased echogenicity, brighter than the right kidney; no focal lesion or collection under the capsule | - |
| Gallbladder and bile ducts | No gallstones; wall not thickened; common bile duct 4 mm, not dilated | - |
| Free fluid | None seen | - |
| Fetus | Single live fetus, cephalic; estimated fetal weight 2600 g (45th centile) | - |
| Liquor, placenta and Doppler | Liquor normal; posterior placenta, no collection behind it; umbilical artery Doppler normal | - |