Lab values beyond the numbers
Objectives
 Recognition of abnormal Lab values
 Treatment of some of the more critical
values
CBC, diff
CBC’S
 White Blood cell = WBC

Differential
• Segs / polys
• Eosinophils
• Basophils
 Hemoglobin
 Hematocrit
 Platelets
•Lymphocytes
•Monocytes
•Bands
Male/Female
Hemoglobin (g/dl)
13.5 - 16.5/11.5-15.5
41 – 50/38-45
Hematocrit (%)
RBC's ( x 106 /ml)
4.5 - 5.5/4-5
RDW (RBC distribution width)
< 14.5
MCV (Mean corpuscular hemoglobin)
80 - 100
MCH (Mean corpuscular volume)
26 - 34
MCHC %
31 - 37
Platelet count
100,000 to 450,000
WBC + differential
WBC (cells/ml)
4,500 - 10,000
Segmented neutrophils
54 - 62%
Basophils
0 - 1 (0 - 0.75%)
Eosinophils
0 - 3 (1 - 3%)
lymphocytes
24 - 44 (25 - 33%)
Monocytes
3 - 6 (3 - 7%)
CBC: WBC
Birth
WBC 9-30
14d
5-20
1y
6-18
4y
5-15
8-21y adult
4.5- 4.513.5 11
36
53
8
2
1
40
53
5
1
1
50
40
8
1
1
60
30
8
1
1
%
poly
lymh
mono
eos
baso
45
30
12
2
1
60
32
4
3
1
CBC: WBC
 Increased Neutrophils

physiologic
• newborn, pregnancy

Pathologic
•
•
•
•
•
•
acute infection
inflammatory dz
metabolic disorder
tissue necrosis
drugs
stress
 Decreased neutrophils

Infection
• bacterial
– typhiod
– septicemia
• Viral
– Hepatitis
– flu
–mono
–measles
• myeloid hypoplasia
• drugs
CBC: WBC
 Increased
Lymphocytes

 Decreased
Lymphocytes
Infection

• Viral:
– Hepatitis
– CMV
–mono
–HSV

• Bacterial
– Pertussis



–mumps
Chronic Inflammation
Metabolic
Hematologic
• ALL


Increased
Corticosteroids
immunodeficiency
miliary Tb
Lupus
CBC: WBC
 Monocytes

Elevated
• mumps
• malaria
• lymphomas
 Eosinophils

Elevated
• Parasitic dz
• allergies
•T-Cell leukemia
•lupus
CBC: Hemoglobin / Hematocrit
 Hemoglobin

Normal
• 1 week: 13-20
• 6months 10.5-14.5
• 10years: 11-16
•1 month: 11-17
•1 year: 11-15
•15years: 14-18M
12-16F
 Hematocrit

Normal
• 14-90d:35-49
• 4-10yr: 31-43
•6m-1yr:30-40
•Adult:42-52M 37-47F
CBC: H/H
 Increased Hct

Polycythemia
• Heart Dz
• Chronic Hypoxia


High Altitude
Hemoconcentration
• Surgery
• Burns
• Dehydration
 Decreased Hct

Anemia
• Malabsorbtion
• Toxin/drugs
– Lead
• Infection
– Malaria
– CMV
• Cancer
Anemia
 NL MCV, MCH
 Retic count:
 High MCV, MCH High:
Blood loss
 Hyperchromic,
Hemolysis
macrocytic
Low:
 Folate, B12
WBC & Plt:
 Early post-bleed
Low:
period (high retic Marrow failure
count)
Leukemia, AA (drug,
toxin,…)
High/NL:
Systemic disease
Infection, renal disease,
Malignancy, chronic
disease
 Low MCV, MCH
 Hypochromic,
microcytic
 Fe deficiency
(90%)
 Thalassemia
 Lead poisoning
 Anemia of chronic
disease
CBC: Platelets
 Platelets


Normal: 150-450 thousand
Decreased platelets
• Decreased production
– Marrow Depression: Aplastic Anemia, Radiation
– Marrow infiltration: Leukemia
– Congenital: Wiskott Aldrich, immune deficiencies
• Increased destruction
– autoimmune: ITP, Mono, SLE
– Coagulopathies: DIC,…
– Drugs
CBC: Platelets

Increased Platelets
• Reactive thrombocytosis
–
–
–
–
infection
splenectomy
surgery/stress
Inflammatory dz.
• Thrombocythemia
– myeloproliferative disorder
– Chronic granulocytic leukemia
Case-study
Ferritin, TIBC, Serum Iron, Transferrin




Total iron binding capacity (TIBC)
Transferrin
Iron (mcg/dl)
Ferritin (ng/ml)
250 - 420 mcg/dl
> 200 mg/dl
65 – 150
13 - 300
B12, Folate
 Folate (ng/dl)
 B12 (pg/ml)
3.6 – 20
200-800
Stool/Exam (S/E)
 ×3 (ova, parasite, …)
 Occult Blood
Inflammatory Index
 ESR
 hs CRP
Chemistries: BUN
 Blood Urea Nitrogen


Normal: 5-20 mg/dl
Elevated
• GI Bleed
• Shock
• Burns

•High Protein Diet
•Dehydration
•Tissue Necrosis
•Steroids
•Diarrhea
Renal Dz
Decreased
• Anabolic Steroids
• Liver Dz
•Malnutrition
•Pregnancy
Chemistries: Cr
 Creatinine


Normal: Child usually less than 1
Increased:
• Renal Dz
• Muscle necrosis
• hypovolemia
Chemistries: Glucose
 Glucose


Normal: 60-110mg/dl (infants >40)
Hyperglycemia
• diabetes
•Pancreatitis
• Cushing's dz
•Pheochromocytoma
• drugs (ie: Steroids)

Hypoglycemia
• Malaria
•liver dz
• enzyme deficiency
•Malignancy
•Malnutrition
Types of glucose tests
 Random Blood sugar
(not fasting)
 Fasting Blood sugar
(nothing to eat or drink except H2O for 12
hrs)
 Glucose Tolerance Test
(Starts fasting, then given sweet drink and
measured over time)
 Hemoglobin A1c
(Measures glucose control over 3 month)
 Glucose, fasting (mg/dl)
60 - 110
 Glucose (2 hours postprandial) (mg/dl) Up to 140
 Hemoglobin A1c
6-8
Diabetes
 Casual plasma glucose concentration >200 mg/dl +
symptoms of diabetes. Casual is defined as any time of day
without regard to time since last meal. The classic
symptoms of diabetes include polyuria, polydipsia and
unexplained weight loss.
 • FPG >126 mg/dl. Fasting is defined as no caloric intake
for at least 8 h.
 • 2-hour post-load glucose >200 mg/dl during an OGTT.
Chemistries: Glucose
 Treatment of Hypoglycemia

Neonate or child: 0.5 to 1 gram / kg
• if using D25 would be 2-4 cc / kg
– dilute D50 1:1 with sterile water
• if using D10 5-10 cc / kg
– dilute D50 1:4

Adult: ampule of D50
Chemistries: Glucose
 Treatment of Hyperglycemia



Fluid bolus 10cc/kg NS
insulin 0.05u - 1 unit/kg
If diabetic in DKA be very judicious of fluid
administration and no NHCO3 unless cardiac
instability
CASE-STUDY
Uric Acid
 Uric acid (male) 2.0 - 8.0 mg/dl
(female) 2.0 - 7.5 mg/dl
CASE - STUDY
Cu, Ceruloplasmin, zinc
 Copper
 Ceruloplasmin
70-155mcg/dl
23-43mg/dl
 Zinc
0.85-1.25mcg/ml
Chemistries: Ca+
 Calcium



Normal 8-11mg/dl
Panic Value:<7 or > 12 (tetni, Sz, arrhythmia)
Hypercalcemia (CHIMPS)
•
•
•
•
•
•
C= Cancer
H= Hyperthyroid
I= Iatrogens
M= Multiple Myeloma
P= Primary Hyperparathyroid
S= Sarcoid
Chemistries: Ca+

Hypocalcemia
•
•
•
•
•
•
•
renal failure
hypoparathyroidism
magnesium deficiency
anticonvulsants
Rickets
Pancreatitis
Blood transfusions
CASE-STUDY
 25 hydroxy vitamin D





>30nmol/l
T3, T4, TSH, Free thyroxin
Alb
PTH
Mg
P
CASE-STUDY
Lipids
 Cholesterol
 HDL
(good cholesterol)
 Ratio
 LDL (bad cholesterol)
 Triglycerides
CASE-STUDY
U/A, U/C
 COLOR (Normal: Yellow to Amber)
– Urochrome gives urine its color. Factors that may alter
color include specific gravity, foods, bilirubin, and drugs
 CHARACTER (Normal: Clear)
– If urine is cloudy or hazy instead of normally clear, it may
be due to white blood cells, bacteria, fecal contamination,
prostatic fluid, or vaginal secretions.
 SPECIFIC GRAVITY (Normal: 1.015-1.025) is the
weight of urine.
A low specific gravity indicates dilute urine and a high
specific gravity indicates concentrated urine.
 pH (Normal: 4.5 –8.0)
- Changes seen with acid base imbalances. Values will
increase with urinary tract infections and if the specimen is
old (ammonia – a base, is produced).
 GLUCOSE (Normal: Negative) – The renal threshold
for blood sugar is 160-180 mg/dl.
 Pregnancy, endocrine, and renal problems can lower the
renal threshold – thus glucose spills over more easily.
 KETONES (Normal: Negative) – Ketones are a
product of fat metabolism.
Causes of ketonuria include DKA, starvation, fasting,
vomiting, strenuous exercise, and dehydration.
 PROTEIN (Normal: Negative)
– Benign conditions that increase protein in urine are stress,
pregnancy, cold, fever, strenuous exercise, and vaginal
secretions.
-Non-benign conditions are hypertension, diabetes (renal
damage), post-renal infection (renal damage), and multiple
myeloma (also serum protein elevated, A/G ratio
abnormal, urine protein up, Bence-Jones proteins up).
 BILIRUBIN (Normal: Negative) - Bilirubin in urine is watersoluble – When bilirubin is present in the urine, it is usually due to a
hepatobiliary obstruction.
 BLOOD (Normal: Negative) –
If positive, urine is usually cloudy. If dipstick is positive, must look at
urine microscopically in the lab for:
 (1) Red Blood Cells (RBCs) (stone, urinary tract infection,
pyelonephritis, glomerulonephritis, renal cancer, bladder cancer,
strenuous exercise, or menses)
 (2) Myoglobin (MI, trauma, crush injuries, or burns)
 (3) Hemoglobin (transfusion reaction, sickle cell, DIC, or
hypertension).
 NITRITE (Normal: Negative)
– Bacteria is broken down into urinary nitrites and nitrate. Nitrites
 are positive when bacteria are in urine.
 LEUKOCYTE ESTERASE (Normal: Negative)
– Reflects presence of white blood cells. Positive findings suggest urinary
tract infection.
 BACTERIA (Normal: Negative)
– If positive, suspect either your patient has a urinary tract infection or the
specimen was contaminated.
 RBCs (RED BLOOD CELLS) (Normal: Negative)
– If >5, think glomerulonephritis, pyelonephritis, renal trauma, tumor,
kidney stones, cystitis, or genitourinary malignancy.
 WBCS (WHITE BLOOD CELLS) (Normal: Negative)
– If > 50, think urinary tract infection.
If < 50, it is usually due to exercise, fever, renal disease, or urinary tract
disease.
 EPITHELIAL CELLS (Normal: Negative)
– When present in large to moderate amounts, worry about either acute
tubular necrosis or acute glomerulonephritis.
 CASTS (Normal: Negative)
- When present, may be due to nephrotic syndrome, glomerulonephritis,
kidney failure, or renal malignancy.
CASE-STUDY
Liver Function Tests
 High enzymes can signal liver damage
(meds, hepatitis, alcohol, drugs)
 ALT (SGPT)
 AST (SGOT)
 Bilirubin yellow fluid produced when RBC’s break down
(liver disease; indinavir and atazanavir can elevate bili)
 Alkaline Phosphatase
 PT, PTT
CASE-STUDY
Other Tests
 Albumin:
major protein in blood
maintains balance in cells;carries nutrients;can affect
other lab tests
CASE-STUDY