1. Chemistry Lab CaseChemistry Lab Case
StudiesStudies
Wichita State UniversityWichita State University
Jennifer Rodgers, ARNP, ACNPJennifer Rodgers, ARNP, ACNP

2. Chemistry PanelsChemistry Panels
 Many names: Chem 7/Chem C/BMP (Na, K,Many names: Chem 7/Chem C/BMP (Na, K,
Cl, TCO2, Glu, BUN, Cr)Cl, TCO2, Glu, BUN, Cr)
 Chem 20/Chem A/CMP (7 Plus Ca, Bili,Chem 20/Chem A/CMP (7 Plus Ca, Bili,
Protein, Albumin, Globulin, A/G Ratio, AlkProtein, Albumin, Globulin, A/G Ratio, Alk
Phos, ALT, AST)Phos, ALT, AST)
 What are you looking for?What are you looking for?
 Know which values to memorizeKnow which values to memorize

3. CHEMISTRY PANELCHEMISTRY PANEL
 TCO2 21-32 mmol/L-Average/rough measurement ofTCO2 21-32 mmol/L-Average/rough measurement of
acid-base balanceacid-base balance
 Total Protein 6.4-8.2 gm/dl-combination pre-Total Protein 6.4-8.2 gm/dl-combination pre-
albumin/albumin/globulinalbumin/albumin/globulin
 Globulin 2.3-3.5 g/dl-building blocks, sign ofGlobulin 2.3-3.5 g/dl-building blocks, sign of
malnutrition & if low albumin/high Globulin/normal Tmalnutrition & if low albumin/high Globulin/normal T
protein >hepatic dysfunctionprotein >hepatic dysfunction

4. CHEMISTRY PANELCHEMISTRY PANEL
 Albumin 3.5-5.0gm/dl-Albumin 3.5-5.0gm/dl-
 Makes up 60% total protein, purpose maintainMakes up 60% total protein, purpose maintain
colloidal osmotic pressure , synthesized in thecolloidal osmotic pressure , synthesized in the
liver, ½ life 12-18 days- MALNUTRITIONliver, ½ life 12-18 days- MALNUTRITION
 Pre-Albumin 16 to 40 mg/dlPre-Albumin 16 to 40 mg/dl
 Shorter half life 2 to 3 days, excellent marker forShorter half life 2 to 3 days, excellent marker for
monitoring Nutritional Supportmonitoring Nutritional Support

5. CHEMISTRY PANELCHEMISTRY PANEL
 A/G Ratio-(Albumin/Globulin) 1.5-2.2, if <1.0A/G Ratio-(Albumin/Globulin) 1.5-2.2, if <1.0
=hepatic dysfunction/SLE, if low serum/urine=hepatic dysfunction/SLE, if low serum/urine
protein electrophoresisprotein electrophoresis
 Total Bili, Alk Phos, ALT, AST>cover laterTotal Bili, Alk Phos, ALT, AST>cover later
 NA, K, Cl, Glu, BUN, Cr>NEED TO KNOWNA, K, Cl, Glu, BUN, Cr>NEED TO KNOW
NORMAL VALUES (where you practice),NORMAL VALUES (where you practice),
CAUSES, & NOW TO TREATCAUSES, & NOW TO TREAT
 Don’t forget Magnesium levelDon’t forget Magnesium level
 If Ca++ abnormal Get PhosphorusIf Ca++ abnormal Get Phosphorus

6. Case StudyCase Study
 36 year old female presents to the ED with36 year old female presents to the ED with
altered mental status, + seizure at the scenealtered mental status, + seizure at the scene
when EMS arrived, multiple skin tears and Stagewhen EMS arrived, multiple skin tears and Stage
III decubitus ulcer to the coccyxIII decubitus ulcer to the coccyx
 BP 90/60 P 110 RR 24 SpO2 93% on 2 litersBP 90/60 P 110 RR 24 SpO2 93% on 2 liters
 What is your differential?What is your differential?
 What tests do you want to order?What tests do you want to order?

7. Case StudyCase Study
 PMH: + ETOH addiction, HTNPMH: + ETOH addiction, HTN
 NKDANKDA
 Currently not taking any medsCurrently not taking any meds
 Social: Single, currently unemployed, quit job 5Social: Single, currently unemployed, quit job 5
months ago, ETOH Large amounts daily ormonths ago, ETOH Large amounts daily or
varying types of liquor, Tobacco: 10 packvarying types of liquor, Tobacco: 10 pack
history. No drugshistory. No drugs

8. Case StudyCase Study
 ROS + For 50 pound weight loss in past 6ROS + For 50 pound weight loss in past 6
months (unintentional), intermittent confusion,months (unintentional), intermittent confusion,
skin tears, decubitus ulcer to coccyx, excoriationskin tears, decubitus ulcer to coccyx, excoriation
to the peri and perianal areato the peri and perianal area
Does this change your differential and tests at all?Does this change your differential and tests at all?

9. Case StudyCase Study
 PE: Thin, pale, cachextic female, lethargic withPE: Thin, pale, cachextic female, lethargic with
minimal verbal responseminimal verbal response
 Poor dentitionPoor dentition
 Skin with pale, warm, dry with poor hygiene,Skin with pale, warm, dry with poor hygiene,
dried feces to coccyx, Stage III decub. Ulcers,dried feces to coccyx, Stage III decub. Ulcers,
multiple areas ecchymosis and skin tearsmultiple areas ecchymosis and skin tears
 HRR no S3 12- Lead STHRR no S3 12- Lead ST
 Abd: Soft non-tender + BS no organomegalyAbd: Soft non-tender + BS no organomegaly
 Ext: trace Lower extremity edemaExt: trace Lower extremity edema

10. Case StudyCase Study
 Further history from the family reveals heavyFurther history from the family reveals heavy
drinking in the past several years, particularlydrinking in the past several years, particularly
worse after her boyfriends death 7 months agoworse after her boyfriends death 7 months ago
 Patient actually quit job due to drinking & hadPatient actually quit job due to drinking & had
not left the house in months, other than tonot left the house in months, other than to
purchase ETOH or have people drop it off.purchase ETOH or have people drop it off.
 The home was found to have molded andThe home was found to have molded and
spoiled food, patient had been defecating onspoiled food, patient had been defecating on
herself the furniture was quite soiledherself the furniture was quite soiled

11. Case StudyCase Study
 Family had attempted to get patient committedFamily had attempted to get patient committed
or other help without successor other help without success
 So what kind of lab would you like to add now?So what kind of lab would you like to add now?

12. Let’s Look at the Admission Lab!Let’s Look at the Admission Lab!
 Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr 0.9 BNP 12Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr 0.9 BNP 12
 Albumin 1.4 Pre-Albumin 8 T Protein 4.2Albumin 1.4 Pre-Albumin 8 T Protein 4.2
 RBC 2.63 Hgb 9.4 Fe 16RBC 2.63 Hgb 9.4 Fe 16
 TSH 0.95TSH 0.95
 Ammonia 16Ammonia 16
 Lactic Acid 2.8Lactic Acid 2.8
 CRP 12.4CRP 12.4
 Ph 7.28 CO2 30 PO2 72 HCO3 14Ph 7.28 CO2 30 PO2 72 HCO3 14

13. Let’s Look at the Admission Lab!Let’s Look at the Admission Lab!
 UA + for Nitrites/LeukocytesUA + for Nitrites/Leukocytes
 CXR- no acute infiltrateCXR- no acute infiltrate
 Head CT- negativeHead CT- negative
 EEG-no seizure activityEEG-no seizure activity
 Drug Screen- negativeDrug Screen- negative
 ETOH 0.010ETOH 0.010

14. What should we do next?What should we do next?
 ABC’s of courseABC’s of course
Bipap, Crystalloids, Consider PressorsBipap, Crystalloids, Consider Pressors
 Elevated CRP + UA +Decub. UlcersElevated CRP + UA +Decub. Ulcers
Broad Spectrum Antibiotics (with anaerobe)Broad Spectrum Antibiotics (with anaerobe)
+ Vancomycin+ Vancomycin
 Seizures/ETOH WithdrawalSeizures/ETOH Withdrawal
Thiamine, Folic Acid, B 12, lorazepam prnThiamine, Folic Acid, B 12, lorazepam prn
seizures, Neuro. consultseizures, Neuro. consult

15. What should we do next?What should we do next?
 Electrolyte ReplacementElectrolyte Replacement
K, Mg, Ph, Na How much? How fast?K, Mg, Ph, Na How much? How fast?
 Nutritional SupplementNutritional Supplement
How much? Re-feeding Syndrome?How much? Re-feeding Syndrome?
Multivitamin with Trace ElementsMultivitamin with Trace Elements
Prevent Aspiration (speech eval.)Prevent Aspiration (speech eval.)

16. What should we do next?What should we do next?
 Wound SupportWound Support
Nutrition, Antibiotics, Wound Team, BedNutrition, Antibiotics, Wound Team, Bed
 AnemiaAnemia
Replace Iron (IV), B12, FolateReplace Iron (IV), B12, Folate
 Await culture results, follow neuro. status, cardiopulm.Await culture results, follow neuro. status, cardiopulm.
status, electrolytes closelystatus, electrolytes closely
 DVT, Ulcer ProphylaxisDVT, Ulcer Prophylaxis

17. Several Days Later….Several Days Later….
 Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7 Hgb 9.6Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7 Hgb 9.6
 Core Temp. dropped to 90.6Core Temp. dropped to 90.6
 WBC 2.4 Bands 60%WBC 2.4 Bands 60%
 Urine + E coliUrine + E coli
 Initial Blood Cultures negativeInitial Blood Cultures negative
 BP 80/40 HR 50 RR 26 (shallow) SpO2 84%BP 80/40 HR 50 RR 26 (shallow) SpO2 84%
on 10 literson 10 liters

18. Several Days Later….Several Days Later….
 What other tests do you want?What other tests do you want?
 What is your differential?What is your differential?
 What do we do next?What do we do next?

19. What Do We Do Next?What Do We Do Next?
 Hypothermia-Place foley with internalHypothermia-Place foley with internal
temperature, warm fluids, warming blanket,temperature, warm fluids, warming blanket,
intubation, 12 Lead & continuous cardiacintubation, 12 Lead & continuous cardiac
monitoring, pressors if fluid alone won’tmonitoring, pressors if fluid alone won’t
maintain adequate MAPmaintain adequate MAP
 Re-culture Blood, Sputum, Urine, CT Head,Re-culture Blood, Sputum, Urine, CT Head,
CXRCXR

20. What happened next?What happened next?
 Extensive Pneumonia, Bilateral InfiltratesExtensive Pneumonia, Bilateral Infiltrates
 Respiratory FailureRespiratory Failure
 Minimal Neuro. ResponseMinimal Neuro. Response
 Despite Mechanical Vent., Broad SpectrumDespite Mechanical Vent., Broad Spectrum
Antibiotics, Nutritional Support, HypothermiaAntibiotics, Nutritional Support, Hypothermia
Treatment, Fluid/Electrolyte Replacement ptTreatment, Fluid/Electrolyte Replacement pt
continued to declinecontinued to decline
 DNR>eventually expiredDNR>eventually expired

21. Case StudyCase Study
 69 year old female presents with increased69 year old female presents with increased
dyspnea, weakness, abdominal pain worseningdyspnea, weakness, abdominal pain worsening
over the past monthover the past month
 BP 110/60 HR 100 RR 24 SpO2 92% 6 litersBP 110/60 HR 100 RR 24 SpO2 92% 6 liters
 What is your differential?What is your differential?
 What tests do you want to order?What tests do you want to order?

22. Case StudyCase Study
 PMH: COPD, Chronic Hypoxemia, TobaccoPMH: COPD, Chronic Hypoxemia, Tobacco
Addiction, HTN, CADAddiction, HTN, CAD
 NKDANKDA
 MEDS: Oxygen, Advair 50/250 1 puff BID,MEDS: Oxygen, Advair 50/250 1 puff BID,
Proventil MDI prn, Lisinopril 10 mg PO q Day,Proventil MDI prn, Lisinopril 10 mg PO q Day,
ASA 81 mg PO q DayASA 81 mg PO q Day
 Does this change your differential?Does this change your differential?

23. Case StudyCase Study
 Social: Single, Retired, 60 pack history, noSocial: Single, Retired, 60 pack history, no
ETOH or drugsETOH or drugs
 ROS: + 25 # unintentional weight loss,ROS: + 25 # unintentional weight loss,
constipation, abdominal swelling, lowerconstipation, abdominal swelling, lower
extremity edema, cough with intermittentextremity edema, cough with intermittent
sputum productionsputum production

24. Case StudyCase Study
 PE: Ill appearing elderly female in no acutePE: Ill appearing elderly female in no acute
distress at restdistress at rest
 + cervical lymphadenopathy+ cervical lymphadenopathy
 HRR + 3/6 murmurHRR + 3/6 murmur
 Faint rales, non laboredFaint rales, non labored
 + spleenomegaly + hepatomegaly+ spleenomegaly + hepatomegaly
 +trace LE edema+trace LE edema
 Additional tests?Additional tests?

25. Lab ResultsLab Results
 Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4
 WBC 12,000 Hgb 9.2 Plt 126,000WBC 12,000 Hgb 9.2 Plt 126,000
 CXR-COPDCXR-COPD
 Abd CT-Enlarged Spleen and Liver with mild ascitesAbd CT-Enlarged Spleen and Liver with mild ascites
 Echo-+MR EF 40%Echo-+MR EF 40%
 12 Lead SR12 Lead SR
 Troponin <0.04Troponin <0.04
 BNP 382BNP 382

26. What do we do next?What do we do next?
 Support, ABC’s, nutrition, watch fluid status,Support, ABC’s, nutrition, watch fluid status,
low dose diuresislow dose diuresis
 Get a tissue biopsy for diagnosisGet a tissue biopsy for diagnosis
 Tissue Biopsy of Cervical Lymph Node revealedTissue Biopsy of Cervical Lymph Node revealed
B cell lymphomaB cell lymphoma

27. Treatment OptionsTreatment Options
 Pt opted to begin chemo therapyPt opted to begin chemo therapy
 Within 24 hours of chemotherapy patient beganWithin 24 hours of chemotherapy patient began
having nausea, vomiting, weakness, parasthesias,having nausea, vomiting, weakness, parasthesias,
dyspnea, and increased edemadyspnea, and increased edema
 What is your differential?What is your differential?

28. What tests do we do now?What tests do we do now?
 STAT Chem 7, Calcium, Phosphorus, LDH,STAT Chem 7, Calcium, Phosphorus, LDH,
Uric Acid, BNP, ABG, CXRUric Acid, BNP, ABG, CXR
 Lab Results K 5.4 Cr 2.3 Ca low Ph high UricLab Results K 5.4 Cr 2.3 Ca low Ph high Uric
Acid high BNP 76 CXR Bilateral mod. PleuralAcid high BNP 76 CXR Bilateral mod. Pleural
EffusionsEffusions
 What is wrong?What is wrong?

29. What do we do now?What do we do now?
 Allopurinol 600-900 mg/day (PO or IV)Allopurinol 600-900 mg/day (PO or IV)
 If not euvolemic Fluids goal urine 3L/day if noIf not euvolemic Fluids goal urine 3L/day if no
underlying cardiovascular issuesunderlying cardiovascular issues
 NaBicarb IVNaBicarb IV
 Diuretics-in well hydrated patients with hyperK+ orDiuretics-in well hydrated patients with hyperK+ or
signs of fluid overloadsigns of fluid overload
 Oral phosphate binders & glucose/insulinOral phosphate binders & glucose/insulin
 HypocalcemiaHypocalcemia
 HemodialysisHemodialysis

30. Case StudyCase Study
 56 year old female presents with increased56 year old female presents with increased
confusion, nausea, vomiting, headache,confusion, nausea, vomiting, headache,
weaknessweakness
 BP 190/100 HR 50 RR 24 SpO2 92% (RA)BP 190/100 HR 50 RR 24 SpO2 92% (RA)
 What is your differential?What is your differential?
 What tests do you want to order?What tests do you want to order?

31. Case StudyCase Study
 PMH: Tobacco Addiction, Lap Chole.,PMH: Tobacco Addiction, Lap Chole.,
Hyperlipidemia, PUDHyperlipidemia, PUD
 NKDANKDA
 MEDS: ASA 81 mg PO Q Day, Simvastatin 80MEDS: ASA 81 mg PO Q Day, Simvastatin 80
mg PO Q Evening, Ranitidine 150 mg PO Qmg PO Q Evening, Ranitidine 150 mg PO Q
SupperSupper
 Does this change your differential?Does this change your differential?

32. Case StudyCase Study
 Social: Married, Accountant, 50 pack history, noSocial: Married, Accountant, 50 pack history, no
ETOH or drugsETOH or drugs
 ROS: + 15 # unintentional weight loss (perROS: + 15 # unintentional weight loss (per
family) otherwise unobtainablefamily) otherwise unobtainable

33. Case StudyCase Study
 PE: Ill appearing elderly female in no acute distress atPE: Ill appearing elderly female in no acute distress at
restrest
 Confused, hyperreflexiaConfused, hyperreflexia
 HRR + pedal pulses + bradycardiaHRR + pedal pulses + bradycardia
 Diminished breath sounds, non laboredDiminished breath sounds, non labored
 Abd Soft, Non-tender + positive bowel soundsAbd Soft, Non-tender + positive bowel sounds
 + Right Axilla lymphadenopathy, palpable Right Breast+ Right Axilla lymphadenopathy, palpable Right Breast
MassMass
 Additional tests?Additional tests?

34. Lab ResultsLab Results
 Na 130 K 4.0 Cr 0.8 Calcium 14.3 Alb 2.8Na 130 K 4.0 Cr 0.8 Calcium 14.3 Alb 2.8
 CRP 15 ESR 96CRP 15 ESR 96
 WBC 15,000 Hgb 9.8 Plt 150,000WBC 15,000 Hgb 9.8 Plt 150,000
 CT Head-NegativeCT Head-Negative
 UA-NegativeUA-Negative
 CT Breast reveals R breast massCT Breast reveals R breast mass

35. What do we do now?What do we do now?
 Treat Hypercalcemia, it is a OncologicTreat Hypercalcemia, it is a Oncologic
EmergencyEmergency
 Pamidronate (Aredia)Pamidronate (Aredia)
 HydrateHydrate
 Prevent aspiration until neuro. statusPrevent aspiration until neuro. status
improvesimproves
 Breast BiopsyBreast Biopsy
 Oncology ConsultOncology Consult

36. SummarySummary
 The Chemistry is a common test that gives theThe Chemistry is a common test that gives the
provider excellent information if reviewedprovider excellent information if reviewed
closely.closely.
 Remember, nothing takes the place of aRemember, nothing takes the place of a
thorough history & physical examination .thorough history & physical examination .