Clinical case study presentation

Clinical case study

1. Clinical Case study Sunny Schemery Professor Tiffany Gill MLT 2015 Decemeber 15, 2014

2. Patient Information 86 year old male came to ER Dizziness Patient was admitted to ICU Dehydration

3. Patient History Malignant neoplasm of descending colon and rectosigmoid and kidney past 7 years Hypovolemia (Blood Volume Depletion) Pancytopenia Bloodstream infection due to central venous catheters

4. Patient Specimens/ Phlebotomy EDTA- CBC/Differential EDTA- Type and screen- Blood Bank Sodium Citrate- Coagulation Urine- urinalysis Serum Separator tube- comprehensive metabolic panel Blood culture bottles- Microbiology Sodium Heparin- Arterial blood gas

5. Abnormal Lab values Hematology

6. Differentials Sep 11 Sep 12 Sep 20 Sep 21 Neutrophils 40-75% 56% 59% 72% 86% H Lymphocytes 20-50% 21% 25% 14% 7% L Atypical Lymphocytes 2% 2% Monocytes 2-9% 16% H 12% H 11% 7% Eosinophils 1-5% 5% 2% 2% 1+ Polychromasia 1+ Polychromasia 1+ Microcytes 1+ Ovalocytes 1+Ovalocytes 1+ Burr cells

7. Coagulation

8. Blood Gases Sep 7 Sep 20 Sep 22 pH 7.35-7.45 7.34 7.34 7.49 PCO2 35-45 mmHg 23.0 28.7 31.3 PO2 80-100 mmHg 90 68 100 HCO3 22-26 mmol /L 12 16 24 O2 sat 94-100% 98 93 99

9. Chemistry CMP Sep 11 Sep 12 Sep 13 Sep 14 Total Protein 4.6 L 5.0 L 5.3 L 4.6 L Albumin 1.8 L 2.1 L 2.0 L 1.9 L Calcium 7.0 L 7.3 L 7.4 L 7.6 L TBilirubin 1.0 1.5 H 1.5 H 1.3 H ALT 13 13 13 11 L AST 35 H 37 H 40 H 35 H Glucose 94 105 148 H 82 BUN 32 H 29 H 27 H 28 H Creatinine 2.4 H 2.4 H 2.3 H 2.5 H Sodium 135 L 135 L 134 L 138 Chloride 101 104 104 110 H CO2 27.9 25.5 21.1 20.5 L

10. CMP Total Protein Low – malabsorption Total Bilirubin High- liver disease Calcium Low- Vitamin D deficinecy Chloride High- Intake IV Sodium Low- renal loss Albumin low- liver disease, nephrotic syndrome AST High- liver disease BUN High- kidney disease Creatinine High- kidney disease

11. Urinalysis Sep 6 Sep 8 Sep 18 Color Yellow Yellow Amber Clarity Slightly cloudy Clear Slightly cloudy Bilirubin Negative Negative Negative Small Ketones Negtaive Negative Negative Trace Blood Negative Large Moderate Moderate Protein Negative Negative Negative 30 mg/ dL RBC 0-5 hpf 10-14 hpf 1-4 hpf 5-9 hpf WBC 0-10 hpf 10-14 hpf 1-4 hpf 5-9 hpf Bacteria Negative present OCC OCC

12. Microbiology Sep 7- Positive for Toxigenic Clostridium difficile Frequent cause of nosocomial infections Sep 9, Sep 12- Positive for Escherichia Coli Causes nosocomial infections Both cause diarrhea All blood cultures after no growth in 5 days Urine cultures Negative

13. medications Tamsulosin - Enlarged prostate Calcium Carbonate- When calcium in diet is not enough Albuterol - Increase airflow to lungs Albumin human- Low protein levels Cefepime - Drug resistant bacteria Cholecalciferol - Form of vitamin D Epoetin Alfa- Treat anemia Loperamide - Used against diarrhea Heparin- cause longer PTT

14. Blood Product Units Type: O POS Screen: Negative Sep 12- 1 unit 250 mL RBCs Leuko -Reduced Sep 19- 3 units; 230mL, 326 mL , 250mL Thawed FP24 Sep 22- 2 units RBCs Leuko -Reduced Sep 22- 1 unit 200 mL platelets Administered for Low Hgb , Low platelet and High PT PTT

15. Diagnosis Primary: Myelodysplastic Syndrome Unspecified - Clonal Stem cell disorder -Share features of all MDSs -Secondary related to prior therapy Secondary: Metabolic acidosis

16. Patient Prognosis/treatment Transfusions to EPO RBCs 30 to 40% of cases lead to acute leukemia

17. References Blaney , K., & Howard, P. (2013). Blood Component Preparation and Therapy. In Basic & applied concepts of blood banking and transfusion practices (3rd ed., p. 312,313,316,317). St. Louis, Mo.: Mosby. Carr, J., & Rodak , B. (2009). Myelodysplastic Syndromes, Diseases affecting Erythrocytes. In Clinical hematology atlas (3rd ed., pp. 177-185, 119-134). St. Louis, Mo.: Saunders Elsevier. Ciesla , B. (2007). The Myleodysplastic Syndromes, Abnormalities of White Blood Cells: Quantative,Qualitative , and the Lipid Storage Diseases. In Hematology in practice (2nd ed., pp. 223-227, 143-155). Philadelphia: F.A. Davis. Engelkirk , P., & Engelkirk , J. (2008). Gram-negative Bacilli: The Family Enterobateracea , Anaerobic Bacteria. In Laboratory diagnosis of infectious diseases: Essentials of diagnostic microbiology (pp. 303-305, 421,422). Baltimore: Wolters Kluwer Health/Lippincott Williams & Wilkins.

18. References Polansky, V. (2014). Clinical Chemistry Review. In Quick review cards for medical laboratory science (pp. 69-133). S.l .: F A Davis. RxList - The Internet Drug Index for prescription drugs, medications and pill identifier. (2014, January 1). Retrieved December 14, 2014, from http://www.rxlist.com/script/main/hp.asp Strasinger , S., & Lorenzo, M. (2008). Chemical examinaton of Urine. In Urinalysis and body fluids (5th ed., pp. 53-75). Philadelphia: F.A. Davis. Sunheimer , R., & Graves, L. (2011). Blood Gases, pH and Acid-Base Balance. In Clinical laboratory chemistry (1st ed., p. 296,297,300). Boston: Pearson.