A 74-year-old African American female was admitted to the emergency department with signs of hypoglycemia, excessive anticoagulation, anemia, and infections. Laboratory tests found abnormal liver and kidney function along with hypothyroidism and rheumatoid arthritis. The patient received treatments including dextrose for hypoglycemia, antibiotics for infections, vitamin K to reverse anticoagulation, blood transfusions for anemia, and prognosis was poor due to multiple declining organ functions and infections.

1. By Keisha M Napper
This presentation is for Professor Gill
College of Southern Maryland
December 15, 2014

2. 
Patient Information

3. 
 74 year old African American female arrives to the
Emergency department by ambulance from a
nursing care facility on September 16, 2014
 Patient medical history:
 Diabetes Mellitus
 Obesity
 Congestive Heart Failure
 Atrial Fibrillation
Patient Information

4. 
Patient Phlebotomy
Patient Abnormal
Values

5. 
 Patient was drawn on 09/16/14 in the emergency
department before being admitted
 Venipuncture tubes received by the laboratory:
Blood culture bottle- Sepsis
Sodium citrate tube – Coagulation studies
Serum separator tube – Comprehensive
Metabolic panel, Chemistry studies
Edta Cross-match tube – ABO/Rh, Type and
Screen
Edta – Complete Blood Count
Patient Phlebotomy

6. 
Comprehensive Metabolic Abnormal Laboratory
Results
Analyte 09/16/1
4 13:33
09/17/14
04:01
09/18/14
03:23
09/19/14
04:01
Reference Ranges
Glucose 41 104 142 153 70-110 mg/dL
BUN 49 54 55 54 8-18 mg/dL
Creatinine 2.7 3.0 2.9 2.5 0.7-1.4 mg/dL
Potassium 5.6 5.4 5.2 4.6 3.5-5.4mmol/L
Calcium 8.2 7.7 7.4 7.4 8.6-10 mg/dL
Tot.
Bilirubin
1.2 1.8 2.0 1.4 0.2-1 mg/dl
Tot. Protein 5.3 5.0 5.3 5.2 6.0-8.0 g/dL
Albumin 2.3 2.3 2.4 2.3 3.5-6.0 g/dL
AST 583 608 353 151 5-30 u/L
ALT 181 217 191 132 6-37 u/L
Patient Abnormal Values

7. 
 On 09/16 patient shows signs of hypoglycemia due to insulin overdose. -
assuming patient is being treated for type 2 diabetes with insulin
 On all days the TP and albumin are decreased while AST and Alt are
elevated w/ AST being more than double on the first three days then being
only slight more increased than the ALT on the 19th. Total bilirubin is also
elevated which indicative of liver disease/ disorder.
 On all days the BUN/Creat/ K (normal on day 4) levels are all elevated
which is most likely due to patient being diabetic causing pre-renal
azotemia and hyperkalemia. On 09/17 GFR was estimated at 15 which for
African Americans 15 – 21 is indicative of stage 3 chronic kidney disease.
 On all days calcium levels are decreased which is indicative of low protein
blood levels, especially albumin, resulting from liver disease and /or
malnutrition that may result from alcoholism
Clinical Indication

8. Cardiac and other Chemistry Laboratory results
Analyte 09/16/1
4 13:33
09/17/14
04:01
09/18/14
03:23
09/19/1
4 04:01
Reference
Ranges
Troponin 0.21 0.37 .023 Not
tested
0.04-0.50
NT
ProBNP
Not
tested
Not
tested
7869 Not
tested
<100 pg/mL
Alcohol Negativ
e
Not
tested
Not
tested
Not
tested
10.90 mg/dL
Magnesiu
m
Not
tested
Not
tested
2.8 Not
tested
1.7-2.2
mg/dL
TSH Not
tested
Not
tested
16.40 Not
tested
0.5-5.0mU/L
RA factor Not
tested
Not
tested
Not
tested
1:64 <1:60 titer
Patient Abnormal
Values

9. 
 On 09/16 Patient had Troponin test – 0.21 which is suggestive of
myocardial damage, and ETOH– negative, CPK 119 in normal ranges
 On 09/17 patient had Troponin test 0.37.
 On 09/18 patient had Mg tested 2.8 (elevated- indicative of kidney failure
and hypothyroidism) TSH 16.40 (elevated- hypothyroidism) Troponin
.023, NT ProBNP 7869 (elevated-patient has history of CHF/Afib and
levels may also be increased due to kidney disease,GFR indicating stage 3
renal failure. Other factors that elevate ProBNP are female sex, liver
cirrhosis, and sepsis)
 On 09/19 patient had RA Factor 1:64 which is indicative of advanced
Rheumatoid arthritis. While the RA Factor is closely associated with RA
other disease can also cause elevated results such as chronic infections and
cirrhosis.
Clinical Indications

10. Coagulation Laboratory Results
Analyte 09/16/14
13:33
09/17/14
04:01
09/18/14
03:23
Reference
Ranges
Pro-time 124.5 sec 28.1 sec 16.8 sec 10-14 sec
INR 10.3 2.50 1.54 1.5-2.0
therapeutic
PTT 43 sec Not tested Not tested 22-45 sec
Patient Abnormal
Values

11.  Assuming that patient is on Coumadin/Warfarin because of CHF/ Afib. It
would be the cause of the excessive anticoagulation seen on 09/16/14. Patient
had a PT of 124.5 seconds and INR of 10.3. Patient has risk factors that could
have possibly lead to the excess anti coagulation, age over 70, leg wound, CHF,
and Afib. Patient most likely was taken off of anticoagulant medication and and
given Vitamin K to bring PT/INR levels back into normal ranges.
 Specific patient characteristics have been identified that are associated with
increased risk of bleeding:
 including advanced age (> 65 yrs);
 history of stroke,
 gastrointestinal bleeding or heart disease
 concurrent aspirin therapy
 atrial fibrillation
 renal insufficiency
 anemia
 long duration of anticoagulant therapy
 hypertension.
Clinical Indication

12. 
Blood products: Type O positive, Negative Antibody Screening
Product 09/16/14 09/16/14 09/17/14 09/17/14
O+ Packed
RBCs
350 mL
16:07-18:00
350 mL
23:30 -09/17/14
02:10
350 mL
09:25-12:50
350mL
14:05-17:55
Thawed
Plasma < 24hrs
244 mL
18:25-19:45
20:40-22:45
Not given Not given Not given
Patient Abnormal
Values

13. 
Complete Blood Count Laboratory Results – post transfusion
Analyte 09/19/14
04:01
09/20/14
03:56
09/21/14
03:56
09/22/14
05:38
Reference
Ranges
RBC 3.6 x 10^3/L 3.56
x10^3/L
3.27
x10^3/L
3.80
x10^3/L
4.0-
5.5x10^3/L
Hgb 9.3 g/dL 9.3 g/dL 8.8 g/dL 10.0 g/dL 12.15 g/dL
Hct 31.1 % 31.0 % 28.4 % 33.0 % 36-48%
MCV 86.4 fl 87.1 fl 86.9 fl 86.8 fl 86-98 fl
MCH 25.8 pg 26.1 pg 26.9 pg 26.3 pg 27-32 pg
MCHC 29.9 g/dL 30.0 g/dL 31.0 g/dL 30.3 g/dL 32-3 g/dL
RDW 18.2 % 18.5 % 18.6 % 19.5 % 11.6-14 %
Plts 207 x10^3/L 210 x10^3/L 186 x10^3/L 198 x10^3/L 150-400 x
10^3/L
Patient Abnormal
Values

14. 
 The CBC results are post transfusion WBC values are
not included because they are in the normal ranges.
Between 09/16 and 9/17 the patient received 350 mL
of packed RBC four times and the patient’s RBC,
Hgb ,Hct, MCH, and MCHC are still below the
normal value which is indicative of anemia and
kidney failure. The decreased MCH and MCHC are
indicative of hypochromia and the elevated RDW is
due to the mixed population of small and large RBC
possible from receiving blood products.
Clinical Indication

15. Urinalysis Laboratory Results 09/16/14 15:00
Color
Clarity
Specific
gravity
Glucose
Bilirubin
Ketones
Blood
pH
Protein
Urobil.
Nitrite
Leuko.
Esterase
WBC
RBC
Bacteria
Dark
yellow
turbid
1.024
Negative
1+
Negative
1+
5.0
2+
1.0
Negative
2+
50+
0-3
TNTC
Urine sample sent to Microbiology department for microbial identification. Plated
on Blood agar and Macconkey Plate. Final results received on 09/19/14. Organism
identified as E. coli >100,000 colonies * ESBL
**Extended spectrum beta-lactamase. ESBLs are enzymes capable of hydrolysing penicillins, broad-spectrum cephalosporins and monobactams. Clinical outcomes
data indicate that ESBLs are clinically significant and, when detected, indicate the need for the use of appropriate antibacterial agents.**
Patient Abnormal
Values

16. 
Microbiology Laboratory Results
09/16/14 13:33 Blood Culture – growth after 24 hours resulted on
09/17/14, organisms identified as MRSA, Staphylococcus epidermis, and
Enterococcus fecium. No growth after five days.
09/16/14 17:57 Nasal swab collected. Resulted at 20:00 positive for MRSA
09/17/14 14:31 Wound swab from left leg collected for culture. Gram stain
showed few gram positive cocci in pairs and clusters with moderate WBC
and few RBC. Resulted on 09/18/14 at 11:55 organism identified as MRSA
heavy growth.
Patient Abnormal
Values

17. 
Treatment

18. 
 Dextrose 50%- 25g IV – hypoglycemia
 Rocephin 1g –IV- bacterial infection, septicemia due to
Staphylococcus aureus
 Vitamin K (phytonadione) 10mg/ p.o. – reverse excessive
anticoagulation
 Thawed plasma <24 hrs.- used to treat bleeding due to
acquired multiple factor deficiency such as large volume
bleeding or DIC. ** patient on anticoagulant therapy with
possible bleeding
 Packed RBC- insufficient tissue oxygen delivery due to
active bleeding/ symptomatic anemia
Patient Treatment

19. 
Prognosis
Diagnosis

20. 
 With proper treatment and ensuring that patient is
not only being administer diabetic medication, but
also eating, patient should not experience diabetic
hypoglycemia.
 Patient needs to have regular laboratory test done to
prevent another episode of excessive
anticoagulation, however the prognosis for this
condition is not good due to the many risk factors
this patient has that contribute to the problem.
 Overall outlook for the patient is poor due to patient
decline in health, renal failure, and liver disorder.
Patient Prognosis

21. 
Patient Diagnosis
Hospital Diagnosis
Diabetic Hypoglycemia
Excessive Anticoagulation
Anemia
Possible Diagnosis
Kidney Failure
Liver Disease/Disorder
Nosocomial MRSA Infection
Rheumatoid Arthritis

22. 
Reference List

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http://www.nclexonline.com/wp-content/uploads/2014/02/normal-lab-values.png
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http://reference.medscape.com/drug/rbcs-red-blood-cells-999507
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procedures/rheumatoid-factor/basics/results/prc-20013484
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