Lab Abnormalities
Dan Crouch
Kristi Kuhn
Kate Lindley
Ben Voss
Case 1
• You arrive for an afternoon ED shift and send your
grateful colleague home. You stop in to evaluate a
24-year-old woman who was signed out to you. She
delivered a healthy term infant one month ago.
While talking to her, you notice her responses are
slow and not very lucid. She complains of vague
abdominal pain, nausea, vomiting, and feeling
“weak all over”. Vowing revenge on your colleague,
who claimed the patient “looked like a million bucks
and should never have come in”, you go to a nearby
computer and look at her labs.
Lab Results – Case 1
11.5
9.3
40
138
106
31
4.0
19
2.4
104
Ca 9.3
PMNs 75%
14.9
1.31
AST 29
ALT 31
38.5
What is most concerning?
Discussion – Case 1
DDx
Management
• TTP (Thrombotic
microangiopathy)
▫ Pregnancy/puerperium
▫ Ultra-large von Willebrand
factor multimers
▫ ADAMTS13 deficiency
(cleaves vWF) due to
neutralizing antibodies
• DIC
▫ Less likely with normal
coags
• Peripheral smear
• Plasma exchange for TTP
• No plts
Case 2
• You are seeing a new patient in the Wohl clinic, a
quiet 72-year-old African-American male. His
son pulls you outside and tells you he thinks his
dad is “really depressed”. The patient states that
he hasn’t been feeling like himself for the past
two months. He feels lethargic, constipated, and
has not been eating well. He mentions that he
was recently in the ER for back pain and was
given some Percocet, which has provided some
relief. You are not satisfied with the diagnosis of
depression and draw some labs.
Lab Results – Case 2
8.1
8.5
350
139
110
45
3.9
28
2.8
92
Ca 10.7
What is most concerning?
Protein 8.2
Albumin 2.0
Bili 0.7
AST 15
ALT 11
Alk phos 191
Discussion – Case 2
DDx
Management
• Malignancy
▫ Multiple Myeloma
• Alkylating agents,
thalidomide, steroids
• Treat hypercalcemia
▫ IVF
▫ Furosemide
• SPEP/UPEP, UA
• BM Bx
• Quantitative Igs
• Skeletal survey
▫ Bisphosphnates
Case 3
• You are on call for Med 2, and you receive a page from a
floor nurse telling you that your next admission, a young
lady with an asthma exacerbation, has arrived from the
ER and “doesn’t look good”. You put away your chicken
fingers and fries and head down the hall to evaluate the
patient. Upon entering her room, you notice that she is
sitting up on the side of the bed and is audibly wheezing.
She tells you in broken sentences that she feels quite
short of breath. You place her on supplemental oxygen,
call respiratory therapy for a bronchodilator treatment
and draw an arterial blood gas. The nurse returns 5
minutes later with the results.
Lab Results – Case 3
•
•
•
•
•
7.30 / 51 / 190
4 L NC O2
A-a gradient 10
HCO3 20
Anion gap 18
Acid-Base Disorder
• Respiratory acidosis
• Gap metabolic acidosis
(For every pCO2 increase by
10, pH decreases 0.08 and
HCO3 increases 1)
Discussion – Case 3
Management
• BiPAP or intubation.
▫ Pt should be alkalotic.
▫ Acidosis is very ominous, an indication that pt has crossed resp.
muscle anaerobic threshold and is generating lactate.
• Stay at bedside, watch pt closely.
▫ Earliest sign that BiPAP is working is reduction in RR.
▫ ABG in 30 mins to look for rise in pH, decrease in pCO2.
▫ If not, intubate.
Case 4
• You have been slaving away in the ER and are nearing
the end of your shift. On the computer tracking system,
you see a new patient has just been checked in and is
waiting to be seen. She is a 25-year-old female with a
complaint of “confusion” per the computer. “How hard
can this be?” you say, and head to her room. When you
arrive, you see a jaundiced, lethargic woman surrounded
by multiple family members. The family states they
hadn’t heard from the patient in several days, so they
went to her house and found her on the bedroom floor
surrounded by empty pill bottles. You start to sweat and
order a bundle of labs. The first ones to come back are
as follows:
Lab Results – Case 4
7.9
13.1
298
141
108
21
4.9
24
1.5
58
Ca 8.9
2.11
41.0
Protein 7.9
Albumin 4.1
Total Bili 6.5
AST 4600
ALT 8450
Alk phos 123
Discussion – Case 4
DDx
Management
• Ingestion
▫ APAP
▫ Alcohol increases
hepatotoxicity of APAP
• NG lavage, activated charcoal
• Tylenol level  check
nomogram
• Check urine & serum drug
screens
• NAC (IV given fulminant
hepatic failure)
• Admit to ICU
• Consider liver transplant
• Note: dialysis not effective
• Pt has many poor prognostic
signs (high ALT/AST, high INR,
high Bili, renal failure)
 P4502E-1 half-life prolonged
 Generates toxic metabolite
Case 5
• You are having a quiet day on the rheumatology
service, writing your last note on a patient with
rheumatoid arthritis who was admitted to the
orthopedic service after an injury. “I love the
surgery floors,” you say to the surgery chief
resident with a smile, “they’re so quiet.”
Suddenly, you hear a nurse shouting for help
down the hall. You run to her aid and find a
little old lady having a generalized tonic-clonic
seizure. Her seizure breaks with one dose of
Ativan. You quickly review her admission labs.
Lab Results – Case 5
9.9
14.6
379
112
82
24
4.3
22
0.9
100
Ca 10.4
UA: specific
gravity 1.050
What is most concerning?
Protein 7.3
Albumin 3.8
Bili 0.3
AST 24
ALT 13
Alk phos 99
Discussion – Case 5
DDx
Management
• Hyponatremia
▫ Assess volume status
▫ (Hypovolemic)
▫ Post-operative increase in
ADH
• IVF: NS until euvolemic
• Correct by 0.5 mEq/L/hr
• If seizing/symptomatic,
correct faster 1-2 mEq/L/hr
with hypertonic saline
• Na[fluid] – Na[pt]/TBW + 1
▫ effect of 1 L IVF on Na
▫ TBW = 0.5 x wt (kg)
▫ Then, determine infusion
rate needed to correct Na by
desired rate.
What if pt was in DKA with a
glucose of 800?
-Corrected Na (1.6 for every
100 over 100) = 123