By Keisha M Napper

This presentation is for Professor Gill

College of Southern Maryland

December 15, 2014

Patient Information

74 year old African American female arrives to the

Emergency department by ambulance from a nursing care facility on September 16, 2014

Patient medical history:

Diabetes Mellitus

Obesity

Congestive Heart Failure

Atrial Fibrillation

Patient Information

Patient Phlebotomy

Patient Abnormal Values

Patient was drawn on 09/16/14 in the emergency

department before being admitted

Venipuncture tubes received by the laboratory:

Blood culture bottle- Sepsis

Sodium citrate tube – Coagulation studies

Serum separator tube – Comprehensive Metabolic panel, Chemistry studies

Edta Cross-match tube – ABO/Rh, Type and Screen

Edta – Complete Blood Count

Patient Phlebotomy

Comprehensive Metabolic Abnormal Laboratory Results

Analyte 09/16/14 13:33

09/17/14 04:01

09/18/14 03:23

09/19/14 04:01

Reference Ranges

Glucose 41 104 142 153 70-110 mg/dL

BUN 49 54 55 54 8-18 mg/dL

Creatinine 2.7 3.0 2.9 2.5 0.7-1.4 mg/dL

Potassium 5.6 5.4 5.2 4.6 3.5-5.4mmol/L

Calcium 8.2 7.7 7.4 7.4 8.6-10 mg/dL

Tot.Bilirubin

1.2 1.8 2.0 1.4 0.2-1 mg/dl

Tot. Protein 5.3 5.0 5.3 5.2 6.0-8.0 g/dL

Albumin 2.3 2.3 2.4 2.3 3.5-6.0 g/dL

AST 583 608 353 151 5-30 u/L

ALT 181 217 191 132 6-37 u/L

Patient Abnormal Values

On 09/16 patient shows signs of hypoglycemia due to insulin overdose. -

assuming patient is being treated for type 2 diabetes with insulin

On all days the TP and albumin are decreased while AST and Alt are elevated w/ AST being more than double on the first three days then being only slight more increased than the ALT on the 19th. Total bilirubin is also elevated which indicative of liver disease/ disorder.

On all days the BUN/Creat/ K (normal on day 4) levels are all elevated which is most likely due to patient being diabetic causing pre-renal azotemia and hyperkalemia. On 09/17 GFR was estimated at 15 which for African Americans 15 – 21 is indicative of stage 3 chronic kidney disease.

On all days calcium levels are decreased which is indicative of low protein blood levels, especially albumin, resulting from liver disease and /or malnutrition that may result from alcoholism

Clinical Indication

Cardiac and other Chemistry Laboratory results

Analyte 09/16/14 13:33

09/17/1404:01

09/18/14 03:23

09/19/14 04:01

Reference Ranges

Troponin 0.21 0.37 .023 Nottested

0.04-0.50

NTProBNP

Not tested

Not tested

7869 Nottested

<100 pg/mL

Alcohol Negative

Nottested

Not tested

Not tested

10.90 mg/dL

Magnesium

Not tested

Not tested

2.8 Not tested

1.7-2.2mg/dL

TSH Not tested

Not tested

16.40 Not tested

0.5-5.0mU/L

RA factor Not tested

Not tested

Not tested

1:64 <1:60 titer

Patient Abnormal Values

On 09/16 Patient had Troponin test – 0.21 which is suggestive of

myocardial damage, and ETOH– negative, CPK 119 in normal ranges

On 09/17 patient had Troponin test 0.37.

On 09/18 patient had Mg tested 2.8 (elevated- indicative of kidney failure and hypothyroidism) TSH 16.40 (elevated- hypothyroidism) Troponin .023, NT ProBNP 7869 (elevated-patient has history of CHF/Afib and levels may also be increased due to kidney disease,GFR indicating stage 3 renal failure. Other factors that elevate ProBNP are female sex, liver cirrhosis, and sepsis)

On 09/19 patient had RA Factor 1:64 which is indicative of advanced Rheumatoid arthritis. While the RA Factor is closely associated with RA other disease can also cause elevated results such as chronic infections and cirrhosis.

Clinical Indications

Coagulation Laboratory Results

Analyte 09/16/14 13:33

09/17/14 04:01

09/18/14 03:23

ReferenceRanges

Pro-time 124.5 sec 28.1 sec 16.8 sec 10-14 sec

INR 10.3 2.50 1.54 1.5-2.0therapeutic

PTT 43 sec Not tested Not tested 22-45 sec

Patient Abnormal Values

Assuming that patient is on Coumadin/Warfarin because of CHF/ Afib. It

would be the cause of the excessive anticoagulation seen on 09/16/14. Patient had a PT of 124.5 seconds and INR of 10.3. Patient has risk factors that could have possibly lead to the excess anti coagulation, age over 70, leg wound, CHF, and Afib. Patient most likely was taken off of anticoagulant medication and and given Vitamin K to bring PT/INR levels back into normal ranges.

Specific patient characteristics have been identified that are associated with increased risk of bleeding:

including advanced age (> 65 yrs); history of stroke, gastrointestinal bleeding or heart disease concurrent aspirin therapy atrial fibrillation renal insufficiency anemia long duration of anticoagulant therapy hypertension.

Clinical Indication

Blood products: Type O positive, Negative Antibody Screening

Product 09/16/14 09/16/14 09/17/14 09/17/14

O+ Packed RBCs

350 mL16:07-18:00

350 mL23:30 -09/17/14 02:10

350 mL09:25-12:50

350mL14:05-17:55

Thawed Plasma < 24hrs

244 mL18:25-19:4520:40-22:45

Not given Not given Not given

Patient Abnormal Values

Complete Blood Count Laboratory Results – post transfusion

Analyte 09/19/1404:01

09/20/1403:56

09/21/14 03:56

09/22/14 05:38

ReferenceRanges

RBC 3.6 x 10^3/L 3.56 x10^3/L

3.27 x10^3/L

3.80 x10^3/L

4.0-5.5x10^3/L

Hgb 9.3 g/dL 9.3 g/dL 8.8 g/dL 10.0 g/dL 12.15 g/dL

Hct 31.1 % 31.0 % 28.4 % 33.0 % 36-48%

MCV 86.4 fl 87.1 fl 86.9 fl 86.8 fl 86-98 fl

MCH 25.8 pg 26.1 pg 26.9 pg 26.3 pg 27-32 pg

MCHC 29.9 g/dL 30.0 g/dL 31.0 g/dL 30.3 g/dL 32-3 g/dL

RDW 18.2 % 18.5 % 18.6 % 19.5 % 11.6-14 %

Plts 207 x10^3/L 210 x10^3/L 186 x10^3/L 198 x10^3/L 150-400 x 10^3/L

Patient Abnormal Values

The CBC results are post transfusion WBC values are

not included because they are in the normal ranges. Between 09/16 and 9/17 the patient received 350 mL of packed RBC four times and the patient’s RBC, Hgb ,Hct, MCH, and MCHC are still below the normal value which is indicative of anemia and kidney failure. The decreased MCH and MCHC are indicative of hypochromia and the elevated RDW is due to the mixed population of small and large RBC possible from receiving blood products.

Clinical Indication

Urinalysis Laboratory Results 09/16/14 15:00

Co

lor

Cla

rity

Sp

ecif

icg

rav

ity

Glu

cose

Bil

iru

bin

Ket

on

es

Blo

od

pH

Pro

tein

Uro

bil

.

Nit

rite

Leu

ko

. E

ster

ase

WB

C

RB

C

Bac

teri

a

Dar

k

yel

low

turb

id

1.02

4

Neg

ativ

e

1+ Neg

ativ

e

1+ 5.0

2+ 1.0

Neg

ativ

e

2+ 50+

0-3

TN

TC

Urine sample sent to Microbiology department for microbial identification. Plated on Blood agar and Macconkey Plate. Final results received on 09/19/14. Organism identified as E. coli >100,000 colonies * ESBL

**Extended spectrum beta-lactamase. ESBLs are enzymes capable of hydrolysing penicillins, broad-spectrum cephalosporins and monobactams. Clinical outcomes data indicate that ESBLs are clinically significant and, when detected, indicate the need for the use of appropriate antibacterial agents.**

Patient Abnormal Values

Microbiology Laboratory Results

09/16/14 13:33 Blood Culture – growth after 24 hours resulted on 09/17/14, organisms identified as MRSA, Staphylococcus epidermis, and Enterococcus fecium. No growth after five days.

09/16/14 17:57 Nasal swab collected. Resulted at 20:00 positive for MRSA

09/17/14 14:31 Wound swab from left leg collected for culture. Gram stain showed few gram positive cocci in pairs and clusters with moderate WBC and few RBC. Resulted on 09/18/14 at 11:55 organism identified as MRSA heavy growth.

Patient Abnormal Values

Treatment

Dextrose 50%- 25g IV – hypoglycemia

Rocephin 1g –IV- bacterial infection, septicemia due to Staphylococcus aureus

Vitamin K (phytonadione) 10mg/ p.o. – reverse excessive anticoagulation

Thawed plasma <24 hrs.- used to treat bleeding due to acquired multiple factor deficiency such as large volume bleeding or DIC. ** patient on anticoagulant therapy with possible bleeding

Packed RBC- insufficient tissue oxygen delivery due to active bleeding/ symptomatic anemia

Patient Treatment

Prognosis

Diagnosis

With proper treatment and ensuring that patient is

not only being administer diabetic medication, but also eating, patient should not experience diabetic hypoglycemia.

Patient needs to have regular laboratory test done to prevent another episode of excessive anticoagulation, however the prognosis for this condition is not good due to the many risk factors this patient has that contribute to the problem.

Overall outlook for the patient is poor due to patient decline in health, renal failure, and liver disorder.

Patient Prognosis

Patient Diagnosis

Hospital Diagnosis

Diabetic Hypoglycemia

Excessive Anticoagulation

Anemia

Possible Diagnosis

Kidney Failure

Liver Disease/Disorder

Nosocomial MRSA Infection

Rheumatoid Arthritis

Reference List

Brain-Type Natriuretic Peptide (BNP) . (n.d.). Retrieved November 23, 2014, from http://emedicine.medscape.com/article/2087425-overview#aw2aab6b3

Ceftriaxone (Rx) - Rocephin. (n.d.). Retrieved November 23, 2014, from http://reference.medscape.com/drug/rocephin-ceftriaxone-342510

Complete Blood Count. (n.d.). Retrieved November 23, 2014, from http://labtestsonline.org/understanding/analytes/cbc/tab/test/

Comprehensive Metabolic Panel. (n.d.). Retrieved November 23, 2014, from http://labtestsonline.org/understanding/analytes/cmp/tab/test/

Dextrose (Rx) - D50W, DGlucose, more..glucose. (n.d.). Retrieved November 23, 2014, from http://reference.medscape.com/drug/d50w-dglucose-dextrose-342705

Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae: Considerations for diagnosis, prevention and drug treatment. (n.d.). Retrieved December 14, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/12558458

Fresh frozen plasma (Blood Component) - FFP, Octaplas. (n.d.). Retrieved November 23, 2014, from http://reference.medscape.com/drug/ffp-octaplas-fresh-frozen-plasma-999499

Liver Panel. (n.d.). Retrieved November 23, 2014, from http://labtestsonline.org/understanding/analytes/liver-panel/tab/test/

Normal lab values. (2014, February 1). Retrieved December 14, 2014, from http://www.nclexonline.com/wp-content/uploads/2014/02/normal-lab-values.png

Over-anticoagulation. (n.d.). Retrieved December 14, 2014, from http://www.emed.ie/Haematology/Over_Anticoagulation.php

Pharmacotherapy. (1999, December 19). Vitamin K to Reverse Excessive Anticoagulation: A Review of the Literature. Retrieved November 23, 2014, from http://www.medscape.com/viewarticle/418081_4

PT and INR. (n.d.). Retrieved November 23, 2014, from http://labtestsonline.org/understanding/analytes/pt/tab/test/

Red blood cells (Blood Component) - RBCs. (n.d.). Retrieved November 23, 2014, from http://reference.medscape.com/drug/rbcs-red-blood-cells-999507

Rheumatoid factor. (n.d.). Retrieved November 23, 2014, from http://www.mayoclinic.org/tests-procedures/rheumatoid-factor/basics/results/prc-20013484

Sunheimer, R., & Graves, L. (2011). Clinical laboratory chemistry. Boston: Pearson.