mlt 2015 clinical case study updated
TRANSCRIPT
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Advance Liver Cirrhosis Disease
With Diabetes Mellitus
Renee BackenMLT-2015
Date: December 3, 2015Professor Tiffany Gill
College of Southern Maryland
Chemistry Case Presentation I
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PATIENT’S INFORMATIO
N
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PATIENT’S INFORMATION
67-year-old Male Patient admitted through Emergency Room via
ambulance from home
After medical work-up patient was admitted to Medical-Surgical unit
Length of stay: 10/14/2015 -10/17/2015
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PATIENT’S HISTORY
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PATIENT’SHISTORY
Advanced Alcoholic Cirrhosis• Currently on the liver transplantation lists
Type 2 Diabetes Mellitus• Insulin required
Chronic Kidney Disease • Probable Stage III
History of esophageal varices• Banding Procedure
History of Iron Deficient Anemia
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SIGNS AND SYMPTOMS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SIGN AND SYMPTOMS
Mental Altered Status and Lethargy
Pale Completions
Significant Ascites
Noted Lower Extremities Edema
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SIGNS AND SYMPTOMS
Afebrile, none of the following symptoms: Shows no signs of chills, nausea, vomiting, diarrhea, rectal bleeding, melena or hematoemesis
No Respiratory discomfort • No SOB, pleurisy, cough, wheezing
No known Cardiac involvement • No chest pain, irregular palpitation, dizziness, syncopal
episodes
No headache, blurred vision, double vision, sore throat, or tinnitus
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SIGNS AND SYMPTOMS
Significant ascites
Noted chronic lower extremity edema
Oxygen saturation with in normal limits on room air
Mucous membranes appears somewhat dry
No evidence of scleral icterus involvement
Does not smoke
Continuation abstinence from alcohol since 2003
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SPECIMEN/PHLEOBOTOMY COLLECTION
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SPECIMEN/PHLEOBOTOMY COLLECTION
Pre-Analytical Work-up
Patient Verification Process
Blood culture • Microbiology-yellow top
Sodium citrate tubes • Coagulation assay-blue top- PT PTT/INR
Heparin tubes-• Chemistry analysis -SST- Light green/Red top
(clot activator) -BMP, CMP, Lactic acid, CTNI, Ammonia)
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
SPECIMEN/PHLEOBOTOMY COLLECTION
K3EDTA Tube• Hematology and Blood Bank-confirmation-
lavender top
K2 EDTA Tube• Blood Bank -ABORH, T & S, major crossmatch units
requested- pink top
Sodium oxalate/fluoride Tube• Respiratory department-lactic acid on ice-gray top-
no tourniquet used
Specimen Transportation to Laboratory• Proper Inversion Performed• Ammonia and lactic acid on ice
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
HEMATOLOGY
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CBC W/ABNORMAL RESULTS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CBC’s COMPARISON GRAPH
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CLINICAL IMPLICATIONS
↑ Monocytes-• Severe Alcohol Cirrhosis
↓ WBC’s, RBC’s, HGB, HCT, MCV, MCH, and Platelets
Indicative of Microcytic, hypochromic Anemia
Pancytopenia• ↓in WBC’s,
RBC’s, Platelets in peripheral blood
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CHEMISTRY
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CMP PANEL
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CMP’S COMPARISON CHART
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
CLINICAL IMPLICATIONS
↑Glucose• Type 2 Diabetes Mellitus
↑Bun• Severe renal impairment
↑Creatinine• Impaired renal function
↓ Sodium ↓ Calcium
• Metabolic & electrolyte imbalance
↓ Total Protein ↓ Albumin
• Acute, Severe, Chronic Liver & Kidney disease
↓ Magnesium• hypomagnesemia
↑ Lactic Acid• Liver and Kidney Damage
↑ Ammonia-• Advance Liver Disease
and Renal failure ↓ Ferritin
• Iron deficiency Anemia
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
BLOOD BANK
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
BLOOD BANKRESULTS
ABO/RH Type A posAntibody Screen PositiveAntibody Panel Identification Anti-E, Panagglutinin, Warm autoantibody, Muliple Antibody, Postive autoantibody Antigen E Type NegativeAHG/Direct Combs Testing IgG PositiveElution Panel Studies (done by ARC) Panaggltuinin, Warm autoantibody
ABORH TYPE AND ANTIBODY PANEL RESULTSTESTS RESULTS
Cross-Matched Packed RBC's Cell Transfusion RecordDate and Time
10/14/2015 10/14/2015 10/16/2015
Tranfusion Reaction
Started 1330 Started 1810 Started 1215 None
Stopped 1625 Stopped 2100 Stopped 1458 None
Amount Given 350 mL 350 mL 350 mL
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
BLOOD BANKRESULTS
Cross-Matched Packed RBC's Cell Transfusion RecordDate and Time
10/14/2015 10/14/2015 10/16/2015 Tranfusion
Reaction
Started 18102110 Started 1330
Started 1215 None
Stopped 21100 Stopped 1625Stopped
1458 None
Amount Given 350 mL 350 mL 350 mL
Typed and Major Crossmatch Compatible• 4 units of A Negative and 2 units of A positive Anti-E
Negative, Antigen E Negative
3 Units Transfused
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
COAGULATION
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
COAGULATION RESULTS WITH CLINICAL IMPLICATIONS
↑Prothrombin Time • Chronic Liver Cirrhosis/Severe
hepatocellular disease
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
URINALYSIS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
URINALYSIS’S RESULTS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
URINALYSIS WITH CLINICAL IMPLICATION
↑ Hyaline cast Granular casts
• Urinary stasis
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
MICROBIOLOGY AND STOOL
OCCULT TEST
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
MICROBIOLOGY AND STOOL OCCULT TEST
GI Track/ Esophageal variceal suspected
Blood Culture • No growth after 48 hours
Peritoneal Fluid• No Growth after 72 hours
OCCULT BLOOD STOOL TEST
TEST 10/14/2015 Performed in ER by Physician 10/14/2015 @ 2326
Negative POSITIVE
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
MEDICATIONS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
MEDICATION ADMINISTERED
IV Solutions and Drugs
Dextrose 50% -Fluid and nutrient replenish
Naloxone HCL-Opioid antagonist
Ondansetron (zofran) -Anti-nausea
Rocephin-Antibiotic
Insulin
Glucagon (IM) Insulin Lispro Insulin Detemir (IM) Oral Vitamins Folic acid Magoxide (magnesium oxide) Vitamin B-1
Sublinqual Nitroglycerin Sublingua
-Nitrates
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
DIAGNOSIS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PATIENT’S DIAGNOSIS
Hepatic Encephalopathy• Advance Liver Cirrhosis
Prerenal etiology• Chronic Diuretic Use
Acute Kidney Injury• Sudden decrease kidney function within a few
hours Pancytopenia
• Aplastic anemia
GI Track Bleed• Underlying Varices bleeding
Hypomagnesemia• ↓Magnesium
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PROGNOSIS
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
PATIENT’S PROGNOSIS
Very good, 80% to 90% survival rate IF liver transplantation occurs
Very poor, death will be imminent if liver transplantation does not occur
Possible kidney dialysis and/or eventually a kidney transplant
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
REFERENCES
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
REFERENCES
Blaney, K., & Howard, P. (2013). Basic & Applied Concepts of Blood Banking and Transfusion Practices (3rd ed.). St. Louis, Missouri: Elsevier Mosby.
Blood Bank Guy.(1998-2015).Panagglutinin. Retrieved December 2, 2015, from http://www.bbguy.org/education/glossary/index.aspx?alphabet=p&id=190
Betty, C. (2012). Normochromic Anemia: Biochemical, Membrane, and Miscellaneous Red Blood Cell Disorders. In Hematology in Practice (2nd ed., pp. 98-109). Philadelphia, Pa 19103: F.A Davis Company.
Drugs.Com.(2000-2015). Dextrose 50 % Injection. Retrieved December 2, 2015, from http://www.drugs.com/pro/dextrose-50-injection.html
Drugs.Com. (2000-2015). Glucagon. Retrieved December 2, 2015, from http://www.drugs.com/mtm/glucagon.html
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
REFERENCES
Drugs.Com. (2000-2015). Insulin-determir. Retrieved December 2, 2015, from http://www.drugs.com/mtm/insulin-detemir.html
Drugs.Com. (2000-2015). Insulin-lispro. Retrieved December 2, 2015 from http://www.drugs.com/mtm/insulin-lispro.html
Drugs.Com. (2000-2015).Magnesium oxide. Retrieved December 2, 2015 from http://www.drugs.com/search.php?searchterm=magnesium+oxide&a=1
Drugs.Com.(2000-2015). Naloxone HCL. Retrieved December 2, 2015, from http://www.drugs.com/mtm/naloxone.html
Drugs.Com. (2000-2015). Nitroglycerin Sublingual. Retrieved December 2, 2015, from http://www.drugs.com/mtm/nitroglycerin.html
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
REFERENCES
Drugs. Com. (2000-2015). Ondansetron . Retrieved December 2, 2015, from http://www.drugs.com/.ondansetron.html
Drugs. Com. (2000-2015).Rocephin. Retrieved December 2, 2015, from http://www.drugs.com/rocephin.htm
Drugs. Com.(2000-2015). Vitamin B-1. Retrieved December 2, 2015, from http;//www.drugs.com/mtm/vitamin_B-1.html
LabCE.(2015).Granular Casts. Retrieved December 2, 2015, from https://www.labce.com/spg30119_granular_casts.aspx
McCall, R., & Tanhersley, C. (2012). Phlebotomy Essentials (5th ed.). Baltimore, MD: Lippincott Williams & Wilkins, A Wolters Kluwer business
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
REFERENCES
McClain, C. (2002). Monocyte activation in alcoholic liver disease. Retrieved December 3, 2015, from http://www.alcoholjournal.org/article/S0741-8329 (02)00212-4/abstract
Medline Plus (n.d). Magnesium Oxide. Retrieved December 2, 2015, from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601074.html
National Kidney Foundation.(2015). ACUTE KIDNEY INJURY (AKI). Retrieved December 3, 2015, from https://www.kidney.org/atoz/content/AcuteKidneyInjury
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Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
Renee BackenMLT-2015Date: December 3, 2015Professor Tiffany GillCollege of Southern Maryland
REFERENCES
NIH U.S National Library of Medicine. (2015). Hepatic encephalopathy. Retrieved December 3, 2015, from https://www.nlm.nih.gov/medlineplus/ency/article/000302.htm
Strasinger, S., & Di Lorenzo, M. (2008). Urinalysis and Body Fluids (5th ed.). Philadelphia, Pa 19103: F.A. Davis Company.
Sunheimer, R., & Graves, L. (2011). Clinical laboratory chemistry. Boston: Pearson.