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Chemistry Lab Case Studies

Chemistry Lab Case Studies. Wichita State University Jennifer Rodgers MSN, APRN, ACNP-BC. 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)

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Chemistry Lab Case Studies

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  1. Chemistry Lab Case Studies Wichita State University Jennifer Rodgers MSN, APRN, ACNP-BC

  2. 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

  3. 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 >hepatic dysfunction

  4. 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

  5. CHEMISTRY PANEL • A/G Ratio-(Albumin/Globulin) 1.5-2.2, if <1.0 =hepatic dysfunction/SLE, if low serum/urine protein electrophoresis • Total Bili, Alk Phos, ALT, AST>cover later • NA, K, Cl, Glu, BUN, Cr>NEED TO KNOW NORMAL VALUES (where you practice), CAUSES, & NOW TO TREAT • Don’t forget Magnesium level • If Ca++ abnormal Get Phosphorus

  6. 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?

  7. 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

  8. 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?

  9. 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

  10. 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

  11. 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?

  12. Let’s 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

  13. Let’s 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

  14. What should we do next? • ABC’s 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

  15. 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.)

  16. 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

  17. 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

  18. Several Days Later…. • What other tests do you want? • What is your differential? • What do we do next?

  19. 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 won’t maintain adequate MAP • Re-culture Blood, Sputum, Urine, CT Head, CXR

  20. 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 • DNR>eventually expired

  21. 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?

  22. 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?

  23. 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

  24. 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?

  25. 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 <0.04 • BNP 382

  26. What do we do next? • Support, ABC’s, nutrition, watch fluid status, low dose diuresis • Get a tissue biopsy for diagnosis • Tissue Biopsy of Cervical Lymph Node revealed B cell lymphoma

  27. 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?

  28. 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?

  29. 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

  30. 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?

  31. 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?

  32. Case Study • Social: Married, Accountant, 50 pack history, no ETOH or drugs • ROS: + 15 # unintentional weight loss (per family) otherwise unobtainable

  33. 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?

  34. 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

  35. 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

  36. 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 .

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