Clinical Case Study

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1. A S H L E Y H A M I L T O N M L T 2 0 1 5 P R O F E S S O R T I F F A N Y G I L L F A L L 2 0 1 5 Clinical Case Study 2. Patient Introduction  Patient is a 71 year…
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  • 1. A S H L E Y H A M I L T O N M L T 2 0 1 5 P R O F E S S O R T I F F A N Y G I L L F A L L 2 0 1 5 Clinical Case Study
  • 2. Patient Introduction  Patient is a 71 year old female  Presented to the ER with shortness of breath, feeling faint, and dizziness  Claims she needed a RBC transfusion
  • 3. Patient History  Diabetes, insulin dependent  Hypertension  Chronic Kidney Disease  Myelodysplastic Syndrome, unspecified  Last blood transfusion: 9/18/15
  • 4. Patient Specimens  Purple top- ETDA for hematology studies  Pink top- EDTA for transfusion services  SST/Gold top- for chemistry studies  Light blue top- sodium citrate for coagulation studies  Urine cup- chemical and microscopic urinalysis
  • 5. C B C W I T H D I F F E R E N T I A L Hematology Lab Results
  • 6. Clinical Implications of Hematology Lab Results  Low blood counts – both WBC and RBC due to bone marrow failure to produce  Low Hemoglobin and Hematocrit –due to low RBC  2 Units of RBCs ordered due to low Hemoglobin  High RDW – double population due to monthly transfusions and abnormal cells produced by the bone marrow
  • 7. Specimen 1 Date: 10/14/15 Time: 0555 Specimen 2 Date: 10/15/15 Time: 0506 Specimen 3 Date: 10/16/15 Time: 0607 WBC 2.3 K/mm3 2.0 K/mm3 2.0 K/mm3 RBC 1.40 M/mm3 1.94 M/mm3 2.68 M/mm3 Hgb 6.5 g/dl 6.0 g/dl 8.4 g/dl Hct 19.7 % 18.1 % 24.5 % MCV 93.9 fl 93.6 fl 91.5 fl MCH 31 pg 31.0 pg 31.3 pg MCHC 33 g/dl 33.1 g/dl 34.2 g/dl RDW 19.2 % 19.5 % 17.5 % PLT 178 K/mm3 179 K/mm3 183 K/mm3 Neutrophils 67.5 % 64.9 % 65.8 % Lymphocytes 22.3 % 26.8 % 25.2 % Monocytes 5.4 % 4.2 % 4.1 % Eosinophiles 3.4 % 2.6 % 3.2 % Basophils 1.4 % 1.5 % 1.7 % L L L L H L L L L H L L L L H
  • 8. C O M P L E T E M E T A B O L I C P A N E L Chemistry Lab Results
  • 9. Clinical Implications of Chemistry Results  The BUN and Creatinine results indicate a problem with the kidney function  High glucose indicates her preexisting diabetes  Low calcium levels due to her kidney disease  Low total protein- borderline low, patient could be a little malnourished coming into the ER
  • 10. Specimen 1 Date:10/14/15 Time: 0555 Specimen 2 Date: 10/15/15 Time: 0506 Specimen 3 Date: 10/16/15 Time: 0607 Specimen 4 Date: 10/17/15 Time: 0525 Glucose 149 mg/dl 146 mg/dl 131 mg/dl 180 mg/dl BUN 49 mg/dl 52 mg/dl 48 mg/dl 49 mg/dl Creatinine 2.6 mg/dl 2.7 mg/dl 2.5 mg/dl 2.3 mg/dl Na 137 mEq/L 137 mEq/L 141 mEq/L 139 mEq/L K 4.5 mEq/L 4.8 mEq/L 4.4 mEq/L 4.4 mEq/L Cl 106 mEq/L 106 mEq/L 109 mEq/L 105 mEq/L Total CO2 22.5 mEq/L 23.9 mEq/L 23.8 mEq/L 24.5 mEq/L Ca 8.3 mg/dl 8.2 mg/dl 8.4 mg/dl 8.1 mg/dl Total Bili 0.2 mg/dl 0.3 mg/dl 0.3 mg/dl 0.2 mg/dl Total Protein 6.0 gm/dl 6.2 gm/dl 6.2 gm/dl 6.2 gm/dl Albumin 3.3 gm/dl 3.6 gm/dl 3.5 gm/dl 3.6 gm/dl ALP 55 U/L 56 U/L 56 U/L 57 U/L AST 12 U/L 12 U/L 13 U/L 14 U/L ALT 8 U/L 8 U/L 9 U/L 10 U/L H H H L L H H H L H H H H L L H H H
  • 11. C H E M I S T R Y A N D M I C R O S C O P I C U R I N A L Y S I S Urinalysis Lab Results
  • 12. Clinical Implications of Urinalysis Results  First Specimen:  High Glucose due to diabetes  WBC, RBC, and Squamous Epithelial cells due to kidney inflammation from diabetes  Second Specimen:  Urinary Tract Infection  Positive Nitrite  TNCT WBC  TNCT Bacteria  1-4/hpf blood
  • 13. Urinalysis Chemistry Results Specimen 1 Date: 07/27/15 Time: 0345 Specimen 2 Date: 10/14/15 Time: 0728 Color Yellow Yellow Clarity Clear Cloudy Specific Gravity 1.011 1.011 Glucose 50 mg/dl Negative Bilirubin Negative Negative Ketones Negative Negative Blood Small Moderate Ph 6.0 5.0 Protein 100 mg/dl 100 mg/dl Urobilinogen <2.0 mg/dl <2.0 mg/dl Nitrite Negative Positive Leukocyte Esterase Trace Large H H H H H H
  • 14. Urinalysis Microscopic Results Specimen 1 Date: 07/27/15 Time: 0345 Specimen 2 Date: 10/14/15 Time: 0728 WBCs 15-29 /hpf TNTC RBCs 5-9 /hpf 1-4 /hpf Squamous Epithelial Cells 1-4 /hpf 1-4 /hpf Transitional Cells Negative Negative RTEs Negative Negative Casts Negative Negative Yeast Negative Negative Bacteria Negative TNTC Mucus Negative Negative Crystals Negative Negative H H HH H H
  • 15. P T / I N R P T T Coagulation Lab Results
  • 16. Clinical Implications of Coagulation Results  Normal PT/INR and PTT results
  • 17. Specimen 1 Date: 07/27/15 Time: 0054 Specimen 2 Date: 10/14/15 Time: 0555 PT/INR 11.1 / 1.0 11.8 / 1.1 PTT 26.0 27.1
  • 18. T Y P E A N T I B O D Y S C R E E N A N T I B O D Y P A N E L Blood Bank Lab Results
  • 19. Date: 10/15/2015 Time: 0442 ABO Typing O Rh Negative Antibody Screening Positive Antibody Present Anti-E, Anti-Jka
  • 20. Units Ordered and Transfused  2 units of packed red cells ordered  2 units of RBC, Anti-E, Anti-Jka ordered from the Red Cross  First unit transfused at 0442 on 10/15/15  Second unit given at 1401 on 10/15/15
  • 21. Clinical Implications of Blood Bank Results  Due to long history of RBC transfusion, she has developed antibodies  Techs often get a result of NSA= Non Specific Antibody  Positive antibody screen result from automated Provue, but negative in manual screen. Provue is more sensitive than manual cells.  This happens when the patients antibody titers are too low to detect, but since the patient has a history of Anti- E, Anti-Jka techs must contact red cross for units.  Many times her blood sample has been sent to Red cross and they perform the cross match. The patient then receives the least incompatible unit.
  • 22. Medication Summary
  • 23. Medications  Carvedilol- High BP  Diphenhydramine HCL – Antihistamine  Insulin- Used to treat Diabetes type 1  Folic Acid- Used to lower homocysteine levels in people with serious kidney disease  Cyanocobalamin- man made B12  Famotidine- acid reflux  Losartan Potassium- treats high blood pressure and helps protect the kidneys from damage due to diabetes.  Sennosides- Laxative  Furosemide- treats edema  Ondansetron HCL- treats nausea  Acetaminophen- pain reliever/fever reducer  Ceftriaxone- antibiotic  Atrovastatin Calcium- reduces LDL, increases HDL
  • 24. Probable Diagnosis
  • 25. Diagnosis/Probable Diagnosis  Primary: Symptomatic anemia  Due to low hemoglobin caused by myelodysplastic syndrome
  • 26. Patient Prognosis
  • 27. Patient Prognosis  Patient has a poor prognosis  The median survival length for MDS patients is 5.5 years with a 14% chance of developing leukemia  Underlying medical problems and age also affect prognosis
  • 28. References
  • 29. References Antihistamine (Oral Route, Parenteral Route, Rectal Route). (2015, December 1). Retrieved December 11, 2015, from http://www.mayoclinic.org/drugs-supplements/antihistamine-oral- route-parenteral-route-rectal-route/description/drg-20070373 Atorvastatin (Oral Route). (2015, December 1). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/atorvastatin-oral-route/description/drg- 20067003 Blaney, K., & Howard, P. (2013). Basic & Applied Concepts of Immunohematology (3rd ed., pp. 126-207). St. Louis, Mo.: Mosby Elsevier. Carvedilol (Oral Route). (2015, December 1). Retrieved December 13, 2015, from http://www.mayoclinic.org/drugs-supplements/carvedilol-oral-route/description/drg-20067565 Ceftriaxone (Injection Route). (2015, December 12). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/ceftriaxone-injection-route/description/drg- 20073123 Cyanocobalamin (Intramuscular Route). (2015, December 1). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/cyanocobalamin-intramuscular- route/description/drg-20137833
  • 30. References Famotidine (Oral Route). (2015, December 1). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/famotidine-oral-route/description/drg-20072972 Furosemide (Oral Route). (2015, December 1). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/furosemide-oral-route/description/drg-20071281 Harmening, D. (2009). Clinical Hematology and Fundamentals of Hemostasis (5th ed., pp. 412- 437). Philadelphia, PA: F.A. Davis. Kidney Disease. (2015, February 25). Retrieved December 1, 2015, from https://labtestsonline.org/understanding/conditions/kidney/start/3 Losartan (Oral Route). (2015, December 1). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/losartan-oral-route/description/drg-20067341 Myelodysplastic Syndrome. (2013, May 17). Retrieved December 1, 2015, from https://labtestsonline.org/understanding/conditions/myelodysplastic-syndrome/start/3 Myelodysplastic syndromes. (2014, November 11). Retrieved December 1, 2015, from http://www.mayoclinic.org/diseases-conditions/myelodysplastic-syndromes/basics/causes/con- 20027168
  • 31. References Ondansetron (Oral Route, Oromucosal Route). (2015, December 1). Retrieved December 10, 2015, from http://www.mayoclinic.org/drugs-supplements/ondansetron-oral-route-oromucosal- route/description/drg-20074421 Sunheimer, R., & Graves, L. (2011). Clinical Laboratory Chemistry (pp. 247-333). Boston: Pearson. Strasinger, S., & Lorenzo, M. (2014). Urinalysis and Body Fluids (6th ed., pp. 148-157). Philadelphia: F.A. Davis. Type 1 diabetes. (2014, August 2). Retrieved December 10, 2015, from http://www.mayoclinic.org/diseases-conditions/type-1-diabetes/basics/definition/con-20019573 Understanding Myelodysplastic Syndromes (MDS) | MDS Foundation. (2014). Retrieved December 1, 2015, from http://www.mds-foundation.org/what-is-mds/
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