Clinical Case Study

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P R O F E S S O R T I F FA N Y G I L LFA L L 2 0 1 5

Clinical Case Study

Patient Introduction

Patient is a 71 year old femalePresented to the ER with shortness of breath,

feeling faint, and dizziness Claims she needed a RBC transfusion

Patient History

Diabetes, insulin dependentHypertension Chronic Kidney Disease Myelodysplastic Syndrome, unspecifiedLast blood transfusion: 9/18/15

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

studiesUrine cup- chemical and microscopic

urinalysis

CBC WITH DIFFERENTIAL

Hematology Lab Results

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

Specimen 1Date: 10/14/15

Time: 0555

Specimen 2 Date: 10/15/15

Time: 0506


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 %

LLLL

H

LLLL

H

LLLL

H

COMPLETE METABOLIC PANEL

Chemistry Lab Results

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 diseaseLow total protein- borderline low, patient

could be a little malnourished coming into the ER

Specimen 1 Date:10/14/15

Time: 0555


Time: 0506


Time: 0607


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

HHH

L

L

HHH

L

HHH

H

L L

HHH

CHEMISTRY AND MICROSCOPIC URINALYSIS

Urinalysis Lab Results

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

Urinalysis Chemistry Results Specimen 1

Date: 07/27/15Time: 0345


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

Urinalysis Microscopic Results Specimen 1

Date: 07/27/15Time: 0345


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

HHH

H

H

PT/ INRPTT

Coagulation Lab Results

Clinical Implications of Coagulation Results

Normal PT/INR and PTT results


Time: 0054


Time: 0555

PT/INR11.1 / 1.0 11.8 / 1.1

PTT26.0 27.1

TYPEANTIBODY SCREENANTIBODY PANEL

Blood Bank Lab Results

Date: 10/15/2015 Time: 0442

ABO Typing O

Rh Negative

Antibody Screening Positive

Antibody Present Anti-E, Anti-Jka

Units Ordered and Transfused

2 units of packed red cells ordered2 units of RBC, Anti-E, Anti-Jka ordered from

the Red CrossFirst unit transfused at 0442 on 10/15/15Second unit given at 1401 on 10/15/15

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 AntibodyPositive 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.

Medication Summary

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

Probable Diagnosis

Diagnosis/Probable Diagnosis

Primary: Symptomatic anemia Due to low hemoglobin caused by myelodysplastic

syndrome

Patient Prognosis

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

References

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

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

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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