Made Incredibly Easy

I have no financial interests or relationships to disclose with regard to the subject matter of this presentation.

DECLARATIONS

Terrance Hartmann, MPAS, PA-C

Graduated in 2010

20yrs total

Related Experience: Ø  Emergency Medicine Ø  Internal Medicine

Current Position: Contracted Internal Medicine PA-C for Immigration and Customs Enforcement

WHAT THIS PRESENTATION WILL BE: •  List of commonly used labs •  COMMON disease states that should be on the

differential of any abnormal labs •  Common pitfalls to avoid

WHAT THIS PRESENTATION WILL NOT BE: •  Overly detailed pathophysiology •  All Inclusive of every known disease •  Medical Zebras

•  CBC •  Anemias •  Infections

•  Cancers

•  Clotting Disorders

•  CMP •  Liver

•  Renal

•  Acid/Base Disorders

•  LIPID PANEL •  TSH

•  A1C

BASIC COMMON LABS or should

be!

More disease specific

•  HIV

•  Thyroid Panel

•  Liver Function Panel (LFT)

•  C-Reactive Protein (CRP)

•  Erythrocyte Sedimentaiton Rate (ESR)

•  Rheumatoid Factor (RA)

•  Antinuclear Antibody (ANA)

•  Cardiac Enzyme Test

•  Etc, etc etc…..

THE “OTHERS”

•  WBC •  Neutrophils •  Lymphocytes

•  Monocytes •  Eosinophils

•  Basophils •  RBC

•  Platelets •  Hemoglobin •  Hematocrit

•  MCV •  MCH

•  RDW

COMPLETE BLOOD COUNT (CBC)

WBC •  Low (Leukopenia) – TB, Leukemia, HIV/AIDS, RA, Sarcoidosis, Lupus, MDS •  High (Leukocytosis) – Various Infections, Inflammation, Polycythemia,

Various Leukemias, TB, Splenectomy, Trauma, Pregnancy, Stress, Strenuous Exercise

•  Generalized Leukocytosis •  Neutrophilia •  Monocytosis •  Eosinophilia •  Basophilia

COMPLETE BLOOD COUNT (CBC)

•  Neutrophils

•  Neutropenia (<1,500) or Agranulocytosis

•  Counts of <500 – Pt is at risk of bacterial infections

•  Aplastic Anemia, Hepatitis, Overactive Spleen, Alcoholism

•  Lymphocytopenia

•  HIV, TB, Autoimmune (RA, Myasthenia Gravis, Lupus)

LEUKOPENIA

LEUKOCYTOSIS •  Neutrophilia – EVERYTHING!! •  Lymphocytosis (>4,000)

•  Peds – Viruses, Pertusis, TB •  Adults – Lymphoid Neoplasm

•  Monocytosis (>1,000) •  Myelogenous Leukemias (AML/CML) •  Myelodysplastic Syndrome (MDS)

•  Eosinophilia (>500) (Wind, Worms, & Weird) •  Allergies •  Parasites •  Asthma

•  Basophilia (>200) •  Neoplastic Syndromes (Hodgkin’s Lymphoma) •  Myeloproliferative Disorders (Thrombocythemia, Myelofibrosis, Polycythemia Vera)

Most

Least

PAY ATTENTION!! Could be bad

etiologies!!

RBC •  Low – Anemia

•  Lack of production – •  Malnutrition/Malabsorption (B12, Folate) •  Suppression – Drugs, Chemotherapy, Lymphoma, Myelodysplasia,

Multiple Myeloma, Kidney Failure •  Early Destruction – Hemolytic Anemia, Thalassemia Diseases, Sickle

Cell, G6PD •  Extravascular Loss – Internal/External Bleeding, Iron Deficiency

•  High – Polycythemia •  Heart Disease, Lung Disease, Dehydration, Polycythemia Vera

COMPLETE BLOOD COUNT (CBC)

•  MCV – LOW (Suggests low production) •  Iron Defciency •  Thalassemias •  Anemia of Chronic Diseases

•  Autoimmune, Malignancy, etc •  Sideroblastic Anemia

•  Malfunctions in bone marrow •  MCV– NORMAL

•  Renal insufficiency •  External blood loss •  Suppressed bone marrow

•  MCV – HIGH •  B12 Deficiency

•  Folate Deficiency •  Myelodysplastic Disorders

•  Other Causes (Liver Disease, Hypothyroid, Drug Therapy)

ANEMIA

Iron Studies, TIBC

Reticulocyte Studies, Renal Studies Liver Function Tests

B12 Levels, Folate Levels, Reticulocyte Studies, Thyroid Panel, Liver Function Test

Recommended Tests

•  Primary - Intrinsic •  Bone Marrow Origin – JAK2 Mutation

•  Secondary – Extrinsic •  Increased EPO secondary to

•  Chronic Hypoxia •  COPD •  Pulmonary HTN •  Emphysema

•  EPO secreting tumor •  Renal Cell Carcinoma •  Adenocarcinoma •  Hepatocellular Carcinoma

POLYCYTHEMIA

Platelets •  Low – Thrombocytopenia

•  Infections – HIV, EBV, Hep-C, Malaria, Sepsis •  Primary Immune Thrombocytopenia •  Pregnancy – HELLP Syndrome (Hemolysis, Elevated LFTs, Low Platelets •  Drugs - Vancomycin, Motrin, Naproxen, Tylenol, Sulfas, Heparin •  Malnutrition •  EToH abuse

•  High – Thrombocytosis •  Primary (Essential) – Leukemia, Polycythemia Vera, •  Secondary (Reactive) – Inflammatory Processes, Splenectomy, Hemorrhage

COMPLETE BLOOD COUNT (CBC)

•  GFR

•  A/G Ratio

•  ALT

•  AST

•  Bilirubin

•  Globulin

•  Albumin

•  Protein

•  Calcium

•  Chloride

COMPLETE METABOLIC COUNT (CMP)

•  Potassium

•  Sodium

•  BUN/Creatinine Ratio

•  Creatinine

•  BUN

•  Glucose

•  CO2

•  Alkaline Phosphate

•  GFR •  Creatinine •  BUN •  ALT •  AST •  Bilirubin

•  Glucose

COMPLETE METABOLIC COUNT (CMP)

•  <6.0 – Type DM and During Pregnancy

•  <7.0 – Most Patients

•  <8.0 – Frail Older Patients

A1C

•  Total Cholesterol

•  Triglycerides

•  HDL

•  VLDL

•  LDL

LIPID PANEL

Just high cholesterol right?

Unless it’s not!

•  Normal Range – 0.4mUL - 5.0 mU/L

•  Primary

•  Autoimmune

•  Inactivation – Surgical/Chemical

•  Secondary

•  Failure of Pituitary or Hypothalamus

TSH

If elevated, repeat with Thyroid Panel

•  17yo male of PMHx significant of depression presents for neurology evaluation of constant HAs and Tinnitus x 1 month. •  Family Hx: Mother EtOH/drug abuse •  SocHx: No known drug/EtOH use

•  Pt recently placed into the care of his brother living in Alaska x 6 months

•  Recent Diagnosis of Depression

•  Neurological S/Sx not improved with depression medications

CASE STUDY #1

•  CBC – Unremarkable

•  CMP – Unremarkable

•  TSH – Unremarkable

•  Toxicology Test: Negative

•  Head CT: Negative

•  EEG: Negative

CASE STUDY #1 LAB/IMAGING RESULTS

•  Diagnosis? •  Simple Depression? Could be!

•  However...look at the ENTIRE situation

•  Moved in with brother and family during the summer break

•  By Thanksgiving Pt has little interest in pleasurable activities

•  By Christmas prone to unprovoked crying, HA and Tinnitus appear

•  Anything missing?

CASE STUDY #1

•  Vitamin D level? •  Never done… •  Specialist assumed it would be done at lower levels.

•  Vitamin D – 10ng/mL •  Deficiency generally defined anything <20ng/mL

•  Alaska daylight hours in Dec/Jan: ±5.5hrs •  1 month s/p Rx of Vit D started:

•  HA’s and Tinnitus resolved •  Depression improving

CASE STUDY #1

•  32yo male of African descent PMHx significant of previously positive PPD presented with cough, wt loss, and fatigue x 6 months. Pt’s recent Chest X-ray showed that he had bilat prominent parenchymal scarring of the mid lungs, but no active TB. Pt states he was started on empiric TB therapy x 2yrs ago for his positive PPD without active TB S/Sx.

•  Pt isolated for presumptive resistant TB and Sputum cultures are obtained.

•  Started on empiric therapy of Rifampin, Isoniazid, Pyrazinamide, Ethambutol.

•  After a few weeks of treatment Pt begins to develop a non-productive cough.

•  Baseline labs that are drawn are:

•  CBC, CMP, Lipid Panel, Liver Function Panel, HIV, RPR

CASE STUDY #2

•  Lipid Panel – Unremarkable

•  HIV – Negative

•  RPR – Negative

CASE STUDY #2 LAB RESULTS

•  CBC – •  WBC: 8.9 x106/uL

•  RBC: 4.1 x106/uL (L)

•  Platelets: 335 x103/uL

•  Hemoglobin: 10.3 g/dL (L)

•  Hematocrit: 30.8% (L)

•  MCV: 75 fL (L)

•  MCH: 25.1 pg (L)

•  RDW: 15.3%

•  CMP – •  GFR: >100 mL/min

•  Creatinine: 0.92 mg/dL

•  BUN: 12 mg/dL

•  ALT: 34 IU/L

•  AST: 26 IU/L

•  Bilirubin: 0.6 mg/dL

•  Glucose: 89 mg/dL

•  Pt’s S/Sx continue to become markedly worse DESPITE TB Therapy x 2 wks

•  Obtained sputum cultures x 3 are negative.

•  Question asked:

•  What did his Iron and TIBC show?

•  Never done…

•  Iron/TIBC ordered and CBC and sputum cultures are reordered.

•  Splenomegaly upon palpation

CASE STUDY #2

CASE STUDY #2 LAB RESULTS #2

•  CBC #2 – •  WBC: 10.7 x106/uL

•  RBC: 3.8 x106/uL (L)

•  Platelets: 588 x103/uL (H)

•  Hemoglobin: 9.3 g/dL (L)

•  Hematocrit: 29.9% (L)

•  MCV: 79 fL

•  MCH: 24.5 pg (L)

•  RDW: 15.3%

•  Iron and TIBC –

•  Iron Sat:

•  Iron,Serum:

•  TIBC:

•  Repeat Sputum Cultures x 3 –

•  Negative

•  Pt still had stable fatigue, cough and low grade temps of 100-101oF

•  Bronchoscopy found no evidence of TB

•  TB Therapy stopped after 2 months of Tx

•  Diagnosis?

•  Still TB according to Infection Disease and Pulmonology Specialists

•  Suspected Thalassemia?

•  Pt refused any more testing and slowly recovered

CASE STUDY #2

•  Follow the “bread crumbs” •  Clinically correlate •  Look at total Patient history •  Investigate inconsistent results •  Watch for dead ends and be willing to

backtrack •  EVERYONE makes mistakes

TAKE AWAYS

•  Tunnel Vision •  Making lab results fit diagnosis •  If it walks/talks/quacks like a duck….

•  It’s probably not a zebra! •  Assumptions

COMMON PITFALLS