Chemistry Lab Case Studies

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Chemistry Lab Case Studies

• Wichita State University
• Jennifer Rodgers
• MSN, APRN, ACNP-BC

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Chemistry Panels

• Many names Chem 7/Chem C/BMP (Na, K, Cl, TCO2,
  Glu, BUN, Cr)
• Chem 20/Chem A/CMP (7 Plus Ca, Bili, Protein,
  Albumin, Globulin, A/G Ratio, Alk Phos, ALT, AST)
• What are you looking for?
• Know which values to memorize

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CHEMISTRY PANEL

• TCO2 21-32 mmol/L-Average/rough measurement of
  acid-base balance
• Total Protein 6.4-8.2 gm/dl-combination
  pre-albumin/albumin/globulin
• Globulin 2.3-3.5 g/dl-building blocks, sign of
  malnutrition if low albumin/high
  Globulin/normal T protein gthepatic dysfunction

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CHEMISTRY PANEL

• Albumin 3.5-5.0gm/dl
• Makes up 60 total protein, purpose maintain
  colloidal osmotic pressure , synthesized in the
  liver, ½ life 12-18 days- MALNUTRITION
• Pre-Albumin 16 to 40 mg/dl
• Shorter half life 2 to 3 days, excellent marker
  for monitoring Nutritional Support

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CHEMISTRY PANEL

• A/G Ratio-(Albumin/Globulin) 1.5-2.2, if lt1.0
  hepatic dysfunction/SLE, if low serum/urine
  protein electrophoresis
• Total Bili, Alk Phos, ALT, ASTgtcover later
• NA, K, Cl, Glu, BUN, CrgtNEED TO KNOW NORMAL
  VALUES (where you practice), CAUSES, NOW TO
  TREAT
• Dont forget Magnesium level
• If Ca abnormal Get Phosphorus

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Case Study

• 36 year old female presents to the ED with
  altered mental status, seizure at the scene
  when EMS arrived, multiple skin tears and Stage
  III decubitus ulcer to the coccyx
• BP 90/60 P 110 RR 24 SpO2 93 on 2 liters
• What is your differential?
• What tests do you want to order?

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Case Study

• PMH ETOH addiction, HTN
• NKDA
• Currently not taking any meds
• Social Single, currently unemployed, quit job 5
  months ago, ETOH Large amounts daily or varying
  types of liquor, Tobacco 10 pack history. No
  drugs

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Case Study

• ROS For 50 pound weight loss in past 6 months
  (unintentional), intermittent confusion, skin
  tears, decubitus ulcer to coccyx, excoriation to
  the peri and perianal area
• Does this change your differential and tests at
  all?

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Case Study

• PE Thin, pale, cachextic female, lethargic with
  minimal verbal response
• Poor dentition
• Skin with pale, warm, dry with poor hygiene,
  dried feces to coccyx, Stage III decub. Ulcers,
  multiple areas ecchymosis and skin tears
• HRR no S3 12- Lead ST
• Abd Soft non-tender BS no organomegaly
• Ext trace Lower extremity edema

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Case Study

• Further history from the family reveals heavy
  drinking in the past several years, particularly
  worse after her boyfriends death 7 months ago
• Patient actually quit job due to drinking had
  not left the house in months, other than to
  purchase ETOH or have people drop it off.
• The home was found to have molded and spoiled
  food, patient had been defecating on herself the
  furniture was quite soiled

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Case Study

• Family had attempted to get patient committed or
  other help without success
• So what kind of lab would you like to add now?

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Lets Look at the Admission Lab!

• Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr 0.9 BNP
  12
• Albumin 1.4 Pre-Albumin 8 T Protein 4.2
• RBC 2.63 Hgb 9.4 Fe 16
• TSH 0.95
• Ammonia 16
• Lactic Acid 2.8
• CRP 12.4
• Ph 7.28 CO2 30 PO2 72 HCO3 14

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Lets Look at the Admission Lab!

• UA for Nitrites/Leukocytes
• CXR- no acute infiltrate
• Head CT- negative
• EEG-no seizure activity
• Drug Screen- negative
• ETOH 0.010

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What should we do next?

• ABCs of course
• Bipap, Crystalloids, Consider Pressors
• Elevated CRP UA Decub. Ulcers
• Broad Spectrum Antibiotics (with anaerobe)
  Vancomycin
• Seizures/ETOH Withdrawal
• Thiamine, Folic Acid, B 12, lorazepam prn
  seizures, Neuro. consult

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What should we do next?

• Electrolyte Replacement
• K, Mg, Ph, Na How much? How fast?
• Nutritional Supplement
• How much? Re-feeding Syndrome?
• Multivitamin with Trace Elements
• Prevent Aspiration (speech eval.)

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What should we do next?

• Wound Support
• Nutrition, Antibiotics, Wound Team, Bed
• Anemia
• Replace Iron (IV), B12, Folate
• Await culture results, follow neuro. status,
  cardiopulm. status, electrolytes closely
• DVT, Ulcer Prophylaxis

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Several Days Later.

• Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7 Hgb 9.6
• Core Temp. dropped to 90.6
• WBC 2.4 Bands 60
• Urine E coli
• Initial Blood Cultures negative
• BP 80/40 HR 50 RR 26 (shallow) SpO2 84 on 10
  liters

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Several Days Later.

• What other tests do you want?
• What is your differential?
• What do we do next?

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What Do We Do Next?

• Hypothermia-Place foley with internal
  temperature, warm fluids, warming blanket,
  intubation, 12 Lead continuous cardiac
  monitoring, pressors if fluid alone wont
  maintain adequate MAP
• Re-culture Blood, Sputum, Urine, CT Head, CXR

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What happened next?

• Extensive Pneumonia, Bilateral Infiltrates
• Respiratory Failure
• Minimal Neuro. Response
• Despite Mechanical Vent., Broad Spectrum
  Antibiotics, Nutritional Support, Hypothermia
  Treatment, Fluid/Electrolyte Replacement pt
  continued to decline
• DNRgteventually expired

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Case Study

• 69 year old female presents with increased
  dyspnea, weakness, abdominal pain worsening over
  the past month
• BP 110/60 HR 100 RR 24 SpO2 92 6 liters
• What is your differential?
• What tests do you want to order?

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Case Study

• PMH COPD, Chronic Hypoxemia, Tobacco Addiction,
  HTN, CAD
• NKDA
• MEDS Oxygen, Advair 50/250 1 puff BID, Proventil
  MDI prn, Lisinopril 10 mg PO q Day, ASA 81 mg PO
  q Day
• Does this change your differential?

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Case Study

• Social Single, Retired, 60 pack history, no ETOH
  or drugs
• ROS 25 unintentional weight loss,
  constipation, abdominal swelling, lower extremity
  edema, cough with intermittent sputum production

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Case Study

• PE Ill appearing elderly female in no acute
  distress at rest
• cervical lymphadenopathy
• HRR 3/6 murmur
• Faint rales, non labored
• spleenomegaly hepatomegaly
• trace LE edema
• Additional tests?

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Lab Results

• Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4
• WBC 12,000 Hgb 9.2 Plt 126,000
• CXR-COPD
• Abd CT-Enlarged Spleen and Liver with mild
  ascites
• Echo-MR EF 40
• 12 Lead SR
• Troponin lt0.04
• BNP 382

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What do we do next?

• Support, ABCs, nutrition, watch fluid status,
  low dose diuresis
• Get a tissue biopsy for diagnosis
• Tissue Biopsy of Cervical Lymph Node revealed B
  cell lymphoma

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Treatment Options

• Pt opted to begin chemo therapy
• Within 24 hours of chemotherapy patient began
  having nausea, vomiting, weakness, parasthesias,
  dyspnea, and increased edema
• What is your differential?

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What tests do we do now?

• STAT Chem 7, Calcium, Phosphorus, LDH, Uric Acid,
  BNP, ABG, CXR
• Lab Results K 5.4 Cr 2.3 Ca low Ph high Uric Acid
  high BNP 76 CXR Bilateral mod. Pleural Effusions
• What is wrong?

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What do we do now?

• Allopurinol 600-900 mg/day (PO or IV)
• If not euvolemic Fluids goal urine 3L/day if no
  underlying cardiovascular issues
• NaBicarb IV
• Diuretics-in well hydrated patients with hyperK
  or signs of fluid overload
• Oral phosphate binders glucose/insulin
• Hypocalcemia
• Hemodialysis

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Case Study

• 56 year old female presents with increased
  confusion, nausea, vomiting, headache, weakness
• BP 190/100 HR 50 RR 24 SpO2 92 (RA)
• What is your differential?
• What tests do you want to order?

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Case Study

• PMH Tobacco Addiction, Lap Chole.,
  Hyperlipidemia, PUD
• NKDA
• MEDS ASA 81 mg PO Q Day, Simvastatin 80 mg PO Q
  Evening, Ranitidine 150 mg PO Q Supper
• Does this change your differential?

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Case Study

• Social Married, Accountant, 50 pack history, no
  ETOH or drugs
• ROS 15 unintentional weight loss (per
  family) otherwise unobtainable

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Case Study

• PE Ill appearing elderly female in no acute
  distress at rest
• Confused, hyperreflexia
• HRR pedal pulses bradycardia
• Diminished breath sounds, non labored
• Abd Soft, Non-tender positive bowel sounds
• Right Axilla lymphadenopathy, palpable Right
  Breast Mass
• Additional tests?

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Lab Results

• Na 130 K 4.0 Cr 0.8 Calcium 14.3 Alb 2.8
• CRP 15 ESR 96
• WBC 15,000 Hgb 9.8 Plt 150,000
• CT Head-Negative
• UA-Negative
• CT Breast reveals R breast mass

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What do we do now?

• Treat Hypercalcemia, it is a Oncologic Emergency
• Pamidronate (Aredia)
• Hydrate
• Prevent aspiration until neuro. status improves
• Breast Biopsy
• Oncology Consult

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Summary

• The Chemistry is a common test that gives the
  provider excellent information if reviewed
  closely.
• Remember, nothing takes the place of a thorough
  history physical examination .