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

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

4. CHEMISTRY PANEL TCO2 21-32 mmol/L-Average/rough measurement of acid-base balance 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 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 Globulin 2.3-3.5 g/dl-building blocks, sign of malnutrition & if low albumin/high Globulin/normal T protein >hepatic dysfunction

5. CHEMISTRY PANEL Albumin 3.5-5.0gm/dl 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 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 Pre-Albumin 16 to 40 mg/dl Shorter half life 2 to 3 days, excellent marker for monitoring Nutritional Support Shorter half life 2 to 3 days, excellent marker for monitoring Nutritional Support

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

7. 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 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 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?

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

9. 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 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?

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

11. Case Study Further history from the family reveals heavy drinking in the past several years, particularly worse after her boyfriends death 7 months ago 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. 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 The home was found to have molded and spoiled food, patient had been defecating on herself the furniture was quite soiled

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

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

14. Let’s Look at the Admission Lab! UA + for Nitrites/Leukocytes UA + for Nitrites/Leukocytes CXR- no acute infiltrate CXR- no acute infiltrate Head CT- negative Head CT- negative EEG-no seizure activity EEG-no seizure activity Drug Screen- negative Drug Screen- negative ETOH 0.010 ETOH 0.010

15. What should we do next? ABC’s of course ABC’s of course Bipap, Crystalloids, Consider Pressors Bipap, Crystalloids, Consider Pressors Elevated CRP + UA +Decub. Ulcers Elevated CRP + UA +Decub. Ulcers Broad Spectrum Antibiotics (with anaerobe) + Vancomycin Broad Spectrum Antibiotics (with anaerobe) + Vancomycin Seizures/ETOH Withdrawal Seizures/ETOH Withdrawal Thiamine, Folic Acid, B 12, lorazepam prn seizures, Neuro. consult

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

17. What should we do next? Wound Support Wound Support Nutrition, Antibiotics, Wound Team, Bed Anemia Anemia Replace Iron (IV), B12, Folate Await culture results, follow neuro. status, cardiopulm. status, electrolytes closely Await culture results, follow neuro. status, cardiopulm. status, electrolytes closely DVT, Ulcer Prophylaxis DVT, Ulcer Prophylaxis

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

19. 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?

20. 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 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 Re-culture Blood, Sputum, Urine, CT Head, CXR

21. What happened next? Extensive Pneumonia, Bilateral Infiltrates Extensive Pneumonia, Bilateral Infiltrates Respiratory Failure Respiratory Failure Minimal Neuro. Response Minimal Neuro. Response Despite Mechanical Vent., Broad Spectrum Antibiotics, Nutritional Support, Hypothermia Treatment, Fluid/Electrolyte Replacement pt continued to decline Despite Mechanical Vent., Broad Spectrum Antibiotics, Nutritional Support, Hypothermia Treatment, Fluid/Electrolyte Replacement pt continued to decline DNR>eventually expired DNR>eventually expired

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

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

24. Case Study Social: Single, Retired, 60 pack history, no ETOH or drugs 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 ROS: + 25 # unintentional weight loss, constipation, abdominal swelling, lower extremity edema, cough with intermittent sputum production

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

26. Lab 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 126,000 WBC 12,000 Hgb 9.2 Plt 126,000 CXR-COPD CXR-COPD Abd CT-Enlarged Spleen and Liver with mild ascites Abd CT-Enlarged Spleen and Liver with mild ascites Echo-+MR EF 40% Echo-+MR EF 40% 12 Lead SR 12 Lead SR Troponin <0.04 Troponin <0.04 BNP 382 BNP 382

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

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

29. What tests do we do now? STAT Chem 7, Calcium, Phosphorus, LDH, Uric Acid, BNP, ABG, CXR 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 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? What is wrong?

30. 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 no underlying cardiovascular issues If not euvolemic Fluids goal urine 3L/day if no underlying cardiovascular issues NaBicarb IV NaBicarb IV Diuretics-in well hydrated patients with hyperK+ or signs of fluid overload Diuretics-in well hydrated patients with hyperK+ or signs of fluid overload Oral phosphate binders & glucose/insulin Oral phosphate binders & glucose/insulin Hypocalcemia Hypocalcemia Hemodialysis Hemodialysis

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

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

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

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

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

36. What do we do now? Treat Hypercalcemia, it is a Oncologic Emergency Treat Hypercalcemia, it is a Oncologic Emergency Pamidronate (Aredia) Pamidronate (Aredia) Hydrate Hydrate Prevent aspiration until neuro. status improves Prevent aspiration until neuro. status improves Breast Biopsy Breast Biopsy Oncology Consult Oncology Consult

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