mlt 2015 clinical case study updated

Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland


Advance Liver Cirrhosis Disease

With Diabetes Mellitus

Renee BackenMLT-2015

Date: December 3, 2015Professor Tiffany Gill

College of Southern Maryland

Chemistry Case Presentation I



PATIENT’S INFORMATIO

N



PATIENT’S INFORMATION

67-year-old Male Patient admitted through Emergency Room via

ambulance from home

After medical work-up patient was admitted to Medical-Surgical unit

Length of stay: 10/14/2015 -10/17/2015



PATIENT’S HISTORY



PATIENT’SHISTORY

Advanced Alcoholic Cirrhosis• Currently on the liver transplantation lists

Type 2 Diabetes Mellitus• Insulin required

Chronic Kidney Disease • Probable Stage III

History of esophageal varices• Banding Procedure

History of Iron Deficient Anemia



SIGNS AND SYMPTOMS



SIGN AND SYMPTOMS

Mental Altered Status and Lethargy

Pale Completions

Significant Ascites

Noted Lower Extremities Edema



SIGNS AND SYMPTOMS

Afebrile, none of the following symptoms: Shows no signs of chills, nausea, vomiting, diarrhea, rectal bleeding, melena or hematoemesis

No Respiratory discomfort • No SOB, pleurisy, cough, wheezing

No known Cardiac involvement • No chest pain, irregular palpitation, dizziness, syncopal

episodes

No headache, blurred vision, double vision, sore throat, or tinnitus



SIGNS AND SYMPTOMS

Significant ascites

Noted chronic lower extremity edema

Oxygen saturation with in normal limits on room air

Mucous membranes appears somewhat dry

No evidence of scleral icterus involvement

Does not smoke

Continuation abstinence from alcohol since 2003



SPECIMEN/PHLEOBOTOMY COLLECTION




Pre-Analytical Work-up

Patient Verification Process

Blood culture • Microbiology-yellow top

Sodium citrate tubes • Coagulation assay-blue top- PT PTT/INR

Heparin tubes-• Chemistry analysis -SST- Light green/Red top

(clot activator) -BMP, CMP, Lactic acid, CTNI, Ammonia)




K3EDTA Tube• Hematology and Blood Bank-confirmation-

lavender top

K2 EDTA Tube• Blood Bank -ABORH, T & S, major crossmatch units

requested- pink top

Sodium oxalate/fluoride Tube• Respiratory department-lactic acid on ice-gray top-

no tourniquet used

Specimen Transportation to Laboratory• Proper Inversion Performed• Ammonia and lactic acid on ice



HEMATOLOGY



CBC W/ABNORMAL RESULTS



CBC’s COMPARISON GRAPH



CLINICAL IMPLICATIONS

↑ Monocytes-• Severe Alcohol Cirrhosis

↓ WBC’s, RBC’s, HGB, HCT, MCV, MCH, and Platelets

Indicative of Microcytic, hypochromic Anemia

Pancytopenia• ↓in WBC’s,

RBC’s, Platelets in peripheral blood



CHEMISTRY



CMP PANEL


CMP’S COMPARISON CHART



CLINICAL IMPLICATIONS

↑Glucose• Type 2 Diabetes Mellitus

↑Bun• Severe renal impairment

↑Creatinine• Impaired renal function

↓ Sodium ↓ Calcium

• Metabolic & electrolyte imbalance

↓ Total Protein ↓ Albumin

• Acute, Severe, Chronic Liver & Kidney disease

↓ Magnesium• hypomagnesemia

↑ Lactic Acid• Liver and Kidney Damage

↑ Ammonia-• Advance Liver Disease

and Renal failure ↓ Ferritin

• Iron deficiency Anemia



BLOOD BANK



BLOOD BANKRESULTS

ABO/RH Type A posAntibody Screen PositiveAntibody Panel Identification Anti-E, Panagglutinin, Warm autoantibody, Muliple Antibody, Postive autoantibody Antigen E Type NegativeAHG/Direct Combs Testing IgG PositiveElution Panel Studies (done by ARC) Panaggltuinin, Warm autoantibody

ABORH TYPE AND ANTIBODY PANEL RESULTSTESTS RESULTS

Cross-Matched Packed RBC's Cell Transfusion RecordDate and Time

10/14/2015 10/14/2015 10/16/2015

Tranfusion Reaction

Started 1330 Started 1810 Started 1215 None

Stopped 1625 Stopped 2100 Stopped 1458 None

Amount Given 350 mL 350 mL 350 mL



BLOOD BANKRESULTS

Cross-Matched Packed RBC's Cell Transfusion RecordDate and Time

10/14/2015 10/14/2015 10/16/2015 Tranfusion

Reaction

Started 18102110 Started 1330

Started 1215 None

Stopped 21100 Stopped 1625Stopped

1458 None

Amount Given 350 mL 350 mL 350 mL

Typed and Major Crossmatch Compatible• 4 units of A Negative and 2 units of A positive Anti-E

Negative, Antigen E Negative

3 Units Transfused



COAGULATION



COAGULATION RESULTS WITH CLINICAL IMPLICATIONS

↑Prothrombin Time • Chronic Liver Cirrhosis/Severe

hepatocellular disease



URINALYSIS



URINALYSIS’S RESULTS



URINALYSIS WITH CLINICAL IMPLICATION

↑ Hyaline cast Granular casts

• Urinary stasis



MICROBIOLOGY AND STOOL

OCCULT TEST



MICROBIOLOGY AND STOOL OCCULT TEST

GI Track/ Esophageal variceal suspected

Blood Culture • No growth after 48 hours

Peritoneal Fluid• No Growth after 72 hours

OCCULT BLOOD STOOL TEST

TEST 10/14/2015 Performed in ER by Physician 10/14/2015 @ 2326

Negative POSITIVE



MEDICATIONS



MEDICATION ADMINISTERED

IV Solutions and Drugs

Dextrose 50% -Fluid and nutrient replenish

Naloxone HCL-Opioid antagonist

Ondansetron (zofran) -Anti-nausea

Rocephin-Antibiotic

Insulin

Glucagon (IM) Insulin Lispro Insulin Detemir (IM) Oral Vitamins Folic acid Magoxide (magnesium oxide) Vitamin B-1

Sublinqual Nitroglycerin Sublingua

-Nitrates



DIAGNOSIS



PATIENT’S DIAGNOSIS

Hepatic Encephalopathy• Advance Liver Cirrhosis

Prerenal etiology• Chronic Diuretic Use

Acute Kidney Injury• Sudden decrease kidney function within a few

hours Pancytopenia

• Aplastic anemia

GI Track Bleed• Underlying Varices bleeding

Hypomagnesemia• ↓Magnesium



PROGNOSIS



PATIENT’S PROGNOSIS

Very good, 80% to 90% survival rate IF liver transplantation occurs

Very poor, death will be imminent if liver transplantation does not occur

Possible kidney dialysis and/or eventually a kidney transplant



REFERENCES



REFERENCES

Blaney, K., & Howard, P. (2013). Basic & Applied Concepts of Blood Banking and Transfusion Practices (3rd ed.). St. Louis, Missouri: Elsevier Mosby.

Blood Bank Guy.(1998-2015).Panagglutinin. Retrieved December 2, 2015, from http://www.bbguy.org/education/glossary/index.aspx?alphabet=p&id=190

Betty, C. (2012). Normochromic Anemia: Biochemical, Membrane, and Miscellaneous Red Blood Cell Disorders. In Hematology in Practice (2nd ed., pp. 98-109). Philadelphia, Pa 19103: F.A Davis Company.

Drugs.Com.(2000-2015). Dextrose 50 % Injection. Retrieved December 2, 2015, from http://www.drugs.com/pro/dextrose-50-injection.html

Drugs.Com. (2000-2015). Glucagon. Retrieved December 2, 2015, from http://www.drugs.com/mtm/glucagon.html



REFERENCES

Drugs.Com. (2000-2015). Insulin-determir. Retrieved December 2, 2015, from http://www.drugs.com/mtm/insulin-detemir.html

Drugs.Com. (2000-2015). Insulin-lispro. Retrieved December 2, 2015 from http://www.drugs.com/mtm/insulin-lispro.html

Drugs.Com. (2000-2015).Magnesium oxide. Retrieved December 2, 2015 from http://www.drugs.com/search.php?searchterm=magnesium+oxide&a=1

Drugs.Com.(2000-2015). Naloxone HCL. Retrieved December 2, 2015, from http://www.drugs.com/mtm/naloxone.html

Drugs.Com. (2000-2015). Nitroglycerin Sublingual. Retrieved December 2, 2015, from http://www.drugs.com/mtm/nitroglycerin.html



REFERENCES

Drugs. Com. (2000-2015). Ondansetron . Retrieved December 2, 2015, from http://www.drugs.com/.ondansetron.html

Drugs. Com. (2000-2015).Rocephin. Retrieved December 2, 2015, from http://www.drugs.com/rocephin.htm

Drugs. Com.(2000-2015). Vitamin B-1. Retrieved December 2, 2015, from http;//www.drugs.com/mtm/vitamin_B-1.html

LabCE.(2015).Granular Casts. Retrieved December 2, 2015, from https://www.labce.com/spg30119_granular_casts.aspx

McCall, R., & Tanhersley, C. (2012). Phlebotomy Essentials (5th ed.). Baltimore, MD: Lippincott Williams & Wilkins, A Wolters Kluwer business



REFERENCES

McClain, C. (2002). Monocyte activation in alcoholic liver disease. Retrieved December 3, 2015, from http://www.alcoholjournal.org/article/S0741-8329 (02)00212-4/abstract

Medline Plus (n.d). Magnesium Oxide. Retrieved December 2, 2015, from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601074.html

National Kidney Foundation.(2015). ACUTE KIDNEY INJURY (AKI). Retrieved December 3, 2015, from https://www.kidney.org/atoz/content/AcuteKidneyInjury



REFERENCES

NIH U.S National Library of Medicine. (2015). Hepatic encephalopathy. Retrieved December 3, 2015, from https://www.nlm.nih.gov/medlineplus/ency/article/000302.htm

Strasinger, S., & Di Lorenzo, M. (2008). Urinalysis and Body Fluids (5th ed.). Philadelphia, Pa 19103: F.A. Davis Company.

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

mlt 2015 clinical case study updated

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