Chemistry Lab Chemistry Lab Case StudiesCase Studies

Wichita State University Wichita State University Jennifer Rodgers, ARNP, Jennifer Rodgers, ARNP,

ACNPACNP

Chemistry PanelsChemistry Panels Many names: Chem 7/Chem C/BMP Many names: Chem 7/Chem C/BMP

(Na, K, Cl, TCO2, Glu, BUN, Cr)(Na, K, Cl, TCO2, Glu, BUN, Cr) Chem 20/Chem A/CMP (7 Plus Ca, Chem 20/Chem A/CMP (7 Plus Ca,

Bili, Protein, Albumin, Globulin, A/G Bili, Protein, Albumin, Globulin, A/G Ratio, Alk Phos, ALT, AST)Ratio, Alk Phos, ALT, AST)

What are you looking for?What are you looking for? Know which values to memorizeKnow which values to memorize

CHEMISTRY PANELCHEMISTRY PANEL TCO2 21-32 mmol/L-Average/rough TCO2 21-32 mmol/L-Average/rough

measurement of acid-base balance measurement of acid-base balance

Total Protein 6.4-8.2 gm/dl-combination pre-Total Protein 6.4-8.2 gm/dl-combination pre-albumin/albumin/globulinalbumin/albumin/globulin

Globulin 2.3-3.5 g/dl-building blocks, sign of Globulin 2.3-3.5 g/dl-building blocks, sign of malnutrition & if low albumin/high malnutrition & if low albumin/high Globulin/normal T protein >hepatic Globulin/normal T protein >hepatic dysfunctiondysfunction

CHEMISTRY PANELCHEMISTRY PANEL Albumin 3.5-5.0gm/dl-Albumin 3.5-5.0gm/dl- Makes up 60% total protein, purpose Makes up 60% total protein, purpose

maintain colloidal osmotic pressure , maintain colloidal osmotic pressure , synthesized in the liver, ½ life 12-18 days- synthesized in the liver, ½ life 12-18 days- MALNUTRITIONMALNUTRITION

Pre-Albumin 16 to 40 mg/dlPre-Albumin 16 to 40 mg/dl Shorter half life 2 to 3 days, excellent Shorter half life 2 to 3 days, excellent

marker for monitoring Nutritional Supportmarker for monitoring Nutritional Support

CHEMISTRY PANELCHEMISTRY PANEL A/G Ratio-(Albumin/Globulin) 1.5-2.2, if A/G Ratio-(Albumin/Globulin) 1.5-2.2, if

<1.0 =hepatic dysfunction/SLE, if low <1.0 =hepatic dysfunction/SLE, if low serum/urine protein electrophoresisserum/urine protein electrophoresis

Total Bili, Alk Phos, ALT, AST>cover Total Bili, Alk Phos, ALT, AST>cover laterlater

NA, K, Cl, Glu, BUN, Cr>NEED TO NA, K, Cl, Glu, BUN, Cr>NEED TO KNOW NORMAL VALUES (where you KNOW NORMAL VALUES (where you practice), CAUSES, & NOW TO TREATpractice), CAUSES, & NOW TO TREAT

Don’t forget Magnesium levelDon’t forget Magnesium level If Ca++ abnormal Get PhosphorusIf Ca++ abnormal Get Phosphorus

Case StudyCase Study 36 year old female presents to the ED with 36 year old female presents to the ED with

altered mental status, + seizure at the altered mental status, + seizure at the scene when EMS arrived, multiple skin scene when EMS arrived, multiple skin tears and Stage III decubitus ulcer to the tears and Stage III decubitus ulcer to the coccyx coccyx

BP 90/60 P 110 RR 24 SpO2 93% on 2 liters BP 90/60 P 110 RR 24 SpO2 93% on 2 liters

What is your differential?What is your differential? What tests do you want to order?What tests do you want to order?

Case StudyCase Study PMH: + ETOH addiction, HTNPMH: + ETOH addiction, HTN NKDANKDA Currently not taking any medsCurrently not taking any meds Social: Single, currently Social: Single, currently

unemployed, quit job 5 months ago, unemployed, quit job 5 months ago, ETOH Large amounts daily or ETOH Large amounts daily or varying types of liquor, Tobacco: 10 varying types of liquor, Tobacco: 10 pack history. No drugspack history. No drugs

Case StudyCase Study ROS + For 50 pound weight loss in ROS + For 50 pound weight loss in

past 6 months (unintentional), past 6 months (unintentional), intermittent confusion, skin tears, intermittent confusion, skin tears, decubitus ulcer to coccyx, excoriation decubitus ulcer to coccyx, excoriation to the peri and perianal areato the peri and perianal area

Does this change your differential and Does this change your differential and tests at all?tests at all?

Case StudyCase Study PE: Thin, pale, cachextic female, lethargic PE: Thin, pale, cachextic female, lethargic

with minimal verbal responsewith minimal verbal response Poor dentitionPoor dentition Skin with pale, warm, dry with poor Skin with pale, warm, dry with poor

hygiene, dried feces to coccyx, Stage III hygiene, dried feces to coccyx, Stage III decub. Ulcers, multiple areas ecchymosis decub. Ulcers, multiple areas ecchymosis and skin tearsand skin tears

HRR no S3 12- Lead STHRR no S3 12- Lead ST Abd: Soft non-tender + BS no organomegalyAbd: Soft non-tender + BS no organomegaly Ext: trace Lower extremity edemaExt: trace Lower extremity edema

Case StudyCase Study Further history from the family reveals Further history from the family reveals

heavy drinking in the past several years, heavy drinking in the past several years, particularly worse after her boyfriends particularly worse after her boyfriends death 7 months agodeath 7 months ago

Patient actually quit job due to drinking & Patient actually quit job due to drinking & had not left the house in months, other had not left the house in months, other than to purchase ETOH or have people than to purchase ETOH or have people drop it off.drop it off.

The home was found to have molded and The home was found to have molded and spoiled food, patient had been defecating spoiled food, patient had been defecating on herself the furniture was quite soiledon herself the furniture was quite soiled

Case StudyCase Study Family had attempted to get patient Family had attempted to get patient

committed or other help without committed or other help without successsuccess

So what kind of lab would you like to So what kind of lab would you like to add now?add now?

Let’s Look at the Let’s Look at the Admission Lab!Admission Lab!

Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr 0.9 BNP 12 0.9 BNP 12

Albumin 1.4 Pre-Albumin 8 T Protein 4.2 Albumin 1.4 Pre-Albumin 8 T Protein 4.2 RBC 2.63 Hgb 9.4 Fe 16RBC 2.63 Hgb 9.4 Fe 16 TSH 0.95TSH 0.95 Ammonia 16Ammonia 16 Lactic Acid 2.8 Lactic Acid 2.8 CRP 12.4CRP 12.4 Ph 7.28 CO2 30 PO2 72 HCO3 14Ph 7.28 CO2 30 PO2 72 HCO3 14

Let’s Look at the Let’s Look at the Admission Lab!Admission Lab!

UA + for Nitrites/LeukocytesUA + for Nitrites/Leukocytes CXR- no acute infiltrate CXR- no acute infiltrate Head CT- negativeHead CT- negative EEG-no seizure activityEEG-no seizure activity Drug Screen- negativeDrug Screen- negative ETOH 0.010ETOH 0.010

What should we do next?What should we do next? ABC’s of courseABC’s of course Bipap, Crystalloids, Consider Bipap, Crystalloids, Consider

PressorsPressors Elevated CRP + UA +Decub. UlcersElevated CRP + UA +Decub. Ulcers Broad Spectrum Antibiotics (with Broad Spectrum Antibiotics (with

anaerobe) anaerobe) + Vancomycin+ Vancomycin Seizures/ETOH WithdrawalSeizures/ETOH Withdrawal

Thiamine, Folic Acid, B 12, lorazepam Thiamine, Folic Acid, B 12, lorazepam prn prn seizures, Neuro. consultseizures, Neuro. consult

What should we do next?What should we do next? Electrolyte ReplacementElectrolyte Replacement

K, Mg, Ph, Na How much? How fast?K, Mg, Ph, Na How much? How fast?

Nutritional SupplementNutritional SupplementHow much? Re-feeding Syndrome?How much? Re-feeding Syndrome?Multivitamin with Trace ElementsMultivitamin with Trace ElementsPrevent Aspiration (speech eval.)Prevent Aspiration (speech eval.)

What should we do next?What should we do next? Wound SupportWound Support

Nutrition, Antibiotics, Wound Team, BedNutrition, Antibiotics, Wound Team, Bed

AnemiaAnemiaReplace Iron (IV), B12, FolateReplace Iron (IV), B12, Folate

Await culture results, follow neuro. status, Await culture results, follow neuro. status, cardiopulm. status, electrolytes closelycardiopulm. status, electrolytes closely

DVT, Ulcer ProphylaxisDVT, Ulcer Prophylaxis

Several Days Later….Several Days Later…. Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7 Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7

Hgb 9.6 Hgb 9.6 Core Temp. dropped to 90.6Core Temp. dropped to 90.6 WBC 2.4 Bands 60%WBC 2.4 Bands 60% Urine + E coli Urine + E coli Initial Blood Cultures negativeInitial Blood Cultures negative BP 80/40 HR 50 RR 26 (shallow) BP 80/40 HR 50 RR 26 (shallow)

SpO2 84% on 10 litersSpO2 84% on 10 liters

Several Days Later….Several Days Later…. What other tests do you want?What other tests do you want?

What is your differential?What is your differential?

What do we do next?What do we do next?

What Do We Do Next?What Do We Do Next? Hypothermia-Place foley with internal Hypothermia-Place foley with internal

temperature, warm fluids, warming temperature, warm fluids, warming blanket, intubation, 12 Lead & blanket, intubation, 12 Lead & continuous cardiac monitoring, continuous cardiac monitoring, pressors if fluid alone won’t maintain pressors if fluid alone won’t maintain adequate MAPadequate MAP

Re-culture Blood, Sputum, Urine, CT Re-culture Blood, Sputum, Urine, CT Head, CXRHead, CXR

What happened next?What happened next? Extensive Pneumonia, Bilateral InfiltratesExtensive Pneumonia, Bilateral Infiltrates Respiratory FailureRespiratory Failure Minimal Neuro. ResponseMinimal Neuro. Response Despite Mechanical Vent., Broad Despite Mechanical Vent., Broad

Spectrum Antibiotics, Nutritional Spectrum Antibiotics, Nutritional Support, Hypothermia Treatment, Support, Hypothermia Treatment, Fluid/Electrolyte Replacement pt Fluid/Electrolyte Replacement pt continued to declinecontinued to decline

DNR>eventually expiredDNR>eventually expired

Case StudyCase Study 69 year old female presents with 69 year old female presents with

increased dyspnea, weakness, abdominal increased dyspnea, weakness, abdominal pain worsening over the past monthpain worsening over the past month

BP 110/60 HR 100 RR 24 SpO2 92% 6 BP 110/60 HR 100 RR 24 SpO2 92% 6 litersliters

What is your differential?What is your differential? What tests do you want to order?What tests do you want to order?

Case StudyCase Study PMH: COPD, Chronic Hypoxemia, PMH: COPD, Chronic Hypoxemia,

Tobacco Addiction, HTN, CADTobacco Addiction, HTN, CAD NKDANKDA MEDS: Oxygen, Advair 50/250 1 puff MEDS: Oxygen, Advair 50/250 1 puff

BID, Proventil MDI prn, Lisinopril 10 BID, Proventil MDI prn, Lisinopril 10 mg PO q Day, ASA 81 mg PO q Daymg PO q Day, ASA 81 mg PO q Day

Does this change your differential?Does this change your differential?

Case StudyCase Study Social: Single, Retired, 60 pack Social: Single, Retired, 60 pack

history, no ETOH or drugshistory, no ETOH or drugs

ROS: + 25 # unintentional weight ROS: + 25 # unintentional weight loss, constipation, abdominal loss, constipation, abdominal swelling, lower extremity edema, swelling, lower extremity edema, cough with intermittent sputum cough with intermittent sputum productionproduction

Case StudyCase Study PE: Ill appearing elderly female in PE: Ill appearing elderly female in

no acute distress at restno acute distress at rest + cervical lymphadenopathy+ cervical lymphadenopathy HRR + 3/6 murmurHRR + 3/6 murmur Faint rales, non laboredFaint rales, non labored + spleenomegaly + hepatomegaly+ spleenomegaly + hepatomegaly +trace LE edema+trace LE edema Additional tests?Additional tests?

Lab ResultsLab Results Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4 Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4 WBC 12,000 Hgb 9.2 Plt 126,000WBC 12,000 Hgb 9.2 Plt 126,000 CXR-COPDCXR-COPD Abd CT-Enlarged Spleen and Liver with Abd CT-Enlarged Spleen and Liver with

mild ascitesmild ascites Echo-+MR EF 40%Echo-+MR EF 40% 12 Lead SR12 Lead SR Troponin <0.04Troponin <0.04 BNP 382BNP 382

What do we do next?What do we do next? Support, ABC’s, nutrition, watch Support, ABC’s, nutrition, watch

fluid status, low dose diuresisfluid status, low dose diuresis

Get a tissue biopsy for diagnosisGet a tissue biopsy for diagnosis

Tissue Biopsy of Cervical Lymph Tissue Biopsy of Cervical Lymph Node revealed B cell lymphomaNode revealed B cell lymphoma

Treatment OptionsTreatment Options Pt opted to begin chemo therapyPt opted to begin chemo therapy

Within 24 hours of chemotherapy Within 24 hours of chemotherapy patient began having nausea, patient began having nausea, vomiting, weakness, parasthesias, vomiting, weakness, parasthesias, dyspnea, and increased edemadyspnea, and increased edema

What is your differential?What is your differential?

What tests do we do What tests do we do now?now?

STAT Chem 7, Calcium, Phosphorus, STAT Chem 7, Calcium, Phosphorus, LDH, Uric Acid, BNP, ABG, CXRLDH, Uric Acid, BNP, ABG, CXR

Lab Results K 5.4 Cr 2.3 Ca low Ph Lab Results K 5.4 Cr 2.3 Ca low Ph high Uric Acid high BNP 76 CXR high Uric Acid high BNP 76 CXR Bilateral mod. Pleural EffusionsBilateral mod. Pleural Effusions

What is wrong?What is wrong?

What do we do now?What do we do now? Allopurinol 600-900 mg/day (PO or IV)Allopurinol 600-900 mg/day (PO or IV) If not euvolemic Fluids goal urine 3L/day If not euvolemic Fluids goal urine 3L/day

if no underlying cardiovascular issuesif no underlying cardiovascular issues NaBicarb IVNaBicarb IV Diuretics-in well hydrated patients with Diuretics-in well hydrated patients with

hyperK+ or signs of fluid overloadhyperK+ or signs of fluid overload Oral phosphate binders & glucose/insulin Oral phosphate binders & glucose/insulin HypocalcemiaHypocalcemia HemodialysisHemodialysis

Case StudyCase Study 56 year old female presents with 56 year old female presents with

increased confusion, nausea, vomiting, increased confusion, nausea, vomiting, headache, weaknessheadache, weakness

BP 190/100 HR 50 RR 24 SpO2 92% BP 190/100 HR 50 RR 24 SpO2 92% (RA)(RA)

What is your differential?What is your differential? What tests do you want to order?What tests do you want to order?

Case StudyCase Study PMH: Tobacco Addiction, Lap PMH: Tobacco Addiction, Lap

Chole., Hyperlipidemia, PUDChole., Hyperlipidemia, PUD NKDANKDA MEDS: ASA 81 mg PO Q Day, MEDS: ASA 81 mg PO Q Day,

Simvastatin 80 mg PO Q Evening, Simvastatin 80 mg PO Q Evening, Ranitidine 150 mg PO Q SupperRanitidine 150 mg PO Q Supper

Does this change your differential?Does this change your differential?

Case StudyCase Study Social: Married, Accountant, 50 pack Social: Married, Accountant, 50 pack

history, no ETOH or drugshistory, no ETOH or drugs

ROS: + 15 # unintentional weight ROS: + 15 # unintentional weight loss (per family) otherwise loss (per family) otherwise unobtainableunobtainable

Case StudyCase Study PE: Ill appearing elderly female in no acute PE: Ill appearing elderly female in no acute

distress at restdistress at rest Confused, hyperreflexiaConfused, hyperreflexia HRR + pedal pulses + bradycardiaHRR + pedal pulses + bradycardia Diminished breath sounds, non laboredDiminished breath sounds, non labored Abd Soft, Non-tender + positive bowel soundsAbd Soft, Non-tender + positive bowel sounds + Right Axilla lymphadenopathy, palpable + Right Axilla lymphadenopathy, palpable

Right Breast MassRight Breast Mass Additional tests?Additional tests?

Lab ResultsLab Results

Na 130 K 4.0 Cr 0.8 Calcium 14.3 Na 130 K 4.0 Cr 0.8 Calcium 14.3 Alb 2.8Alb 2.8

CRP 15 ESR 96CRP 15 ESR 96 WBC 15,000 Hgb 9.8 Plt 150,000WBC 15,000 Hgb 9.8 Plt 150,000 CT Head-NegativeCT Head-Negative UA-NegativeUA-Negative CT Breast reveals R breast massCT Breast reveals R breast mass

What do we do now?What do we do now? Treat Hypercalcemia, it is a Treat Hypercalcemia, it is a

Oncologic EmergencyOncologic Emergency Pamidronate (Aredia)Pamidronate (Aredia) HydrateHydrate Prevent aspiration until neuro. Prevent aspiration until neuro.

status improvesstatus improves Breast BiopsyBreast Biopsy Oncology ConsultOncology Consult

SummarySummary The Chemistry is a common test that The Chemistry is a common test that

gives the provider excellent gives the provider excellent information if reviewed closely.information if reviewed closely.

Remember, nothing takes the place Remember, nothing takes the place of a thorough history & physical of a thorough history & physical examination .examination .