Case Studies Clinical Biochemistry
Patient: 29 year old female
GP request
History:
Feeling tired; Weight gain
Results:
Reference Interval
fT4 12 pmol/L (9-19)
TSH 6.5 U/L (0.5-4.2)
•
Patient: 57 year old male
Clinical Notes: GP request ? diabetes mellitus
Glucose tolerance test: 75g Glucose load given.
Results:
Sample Plasma Glucose
Fasting 5.7 mmol/L
60 minutes post glucose load 5.9 mmol/L
120 minutes post glucose load 5.8 mmol/L
Patient: A 41-year-old female presented to the Emergency Department with fever, abdominal pain and vomiting. The patient has a background history of left breast carcinoma with metastasis to the lung, bone and liver. She underwent surgery, chemotherapy and radiotherapy.
Results: (Reference Interval)
Sodium 138 135 – 145 mmol/L
Potassium 2.5 3.3 – 4.9 mmol/L
Chloride 96 96 – 108 mmol/L
Bicarbonate 27 19 – 31 mmol/L
Urea 3.1 2.8 – 7.7 mmol/L
Creatinine 25 40 – 85 μmol/L
Calcium 1.68 2.1 – 2.6 mmol/L
Phosphate 0.36 0.77 – 1.38 mmol/L
Albumin 29 37 – 51 g/L
PTH 5.0 0.9 – 6.2 pmol/L
Patient: A 45-year-old female presented to her general practitioner for a checkup. The clinical notes are abnormal LFTs. There are no previous results available.
Results: (Reference Interval)
Ferritin 420 ug/L 10 – 205
Iron 17 umol/L 11 – 32
Transferrin 17 umol/L 20 – 40
Transferrin Saturation 49 % 15 - 40
Areas of Pre and Post Analytical Error
• Phlebotomy procedures/training
• Identification of patient
• Patient preparation factors
• Specimen rejection
• Critical results procedures
Patient: A 37-year-old female presented to her general practitioner for a checkup. The clinical notes are non-pregnant and overweight. There are no previous results available.
Results: (Reference Interval)
Fasting Glucose 6.4 mmol/L 3.0 – 5.5
Patient presents with a history of acute bleeding from a gastric ulcer
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Calcium
Phosphate
Urea
Glucose
T.Protein
T.Bilirubin
ALP
ALT
GGT
169
3.6
81
22
66
1.78
1.6
7.3
28.4
71
9
19
22
57
135-145
3.5-4.5
100-110
24-32
5-15
2.10-2.55
0.9-1.5
<7.5
<8.0
62-80
<20
<115
<40
<60
Case 1
How would you investigate this sample?
Bicarbonate - acid
Calcium - lowered
(bound)
Phosphate - elevated
Glucose - elevated
Alk Phos
Haemochromatosis
Venesection
History
Collection Set
Sodium Citrate-Phosphate
Dextrose
Adenine
Contents of
blood collection bag
Case 2
What’s happened
TUTORIAL Week 1
1/6 1/12 2/12 RI
Hb 140 90 138 130-170
WCC 5.5 2.1 5.6 4.0-10.0
Plt 420 5 415 150-400
Case 2
Possible causes:
Clot
Wrong Patient
The wrong Patient
• Why would you mix up two patients?
• In the community?
• In hospital • Babies
• Adults
Case 3
Healthy patient presents with the following result of Calcium
Calcium 1.68 mmol/L ( 2.02-2.55 )
Case 3
What procedures do you have in place to deal with a result such as this?
SOP
Repeat
Recollect?
Causes?
Case 4
Routine Electrolyte Profile
Sodium 135 mmol/L ( 135-145 )
Potassium 6.6 mmol/L ( 3.5-4.5 )
Urea 4.8 mmol/L ( 3.0- 8.0 )
Creatinine 89 umol/L (60 -110 )
Case 4
How would you deal with this result?
SOP
Repeat
Examine sample?
Recollect?
Causes?
Case 5
A collector asks about fasting?
What is a fasting sample?
Case 5
What instructions should be given to the collectors?
Case 6
A patient is on digoxin for congestive cardiac failure.
How long after the last dose should blood be drawn?
Case 7
A 9 month old child is found to have a blood lead of 12.1 umol/L (<0.2 umol/L)
How would you investigate this child?
Case 7
Is this possible?
How are these samples collected?
What may have happened?
Program
• Liver Function Tests
LFTs
• ‘Cell sap’ enzymes - AsT, AlT
• ‘Biliary tree’ enzymes - ALP, GGT
• Bilirubin - conjugated, unconjugated
• Other - LD, albumin, globulins
LFTs
• Individual enzymes non-specific and insensitive
• ‘Patterns’ of enzymes important
• Patterns change with course of disease
• Clinical history critical
The 4 Common Patterns
• Hepatocellular damage
• Duct obstruction
• Mixed (Hepatocellular/duct)
• Other
Pathology of Disease
• Inflammation - changes to environment (toxin,
nutrient (O2), infection) -> ‘cell swells and leaks’
• Necrosis - loss of cellular contents
• Rebuilding
Mac Kay - Male 14
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
78
46
32
36
12
72
2300
2215
22
3410
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Clinical details
• Fevers, diarrhoea, anorexia, abdo pain, sore throat
H Hill - Female 30
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
74
44
30
31
15
108
744
531
86
598
Day 4
71
42
29
8
2
96
60
212
75
144
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Clinical details
• IV Drug user
C Towers - Male 77
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
55
30
25
30
9
55
2828
1916
101
3124
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Clinical details
• Cardiac arrest
T Ville - Male 67
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
55
30
25
9
<3
255
28
16
101
524
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Clon Curry - Female 53
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
77
42
25
139
120
455
34
38
601
224
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Rock H Ton - Female 56
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
65
39
26
96
72
1845
225
305
860
183
R.range
63-80
35-50
21-41
3-20
0-7
30-115
5-40
5.40
5-65
100-225
Clinical details
• Pain, anorexia, weight loss, itch, jaundice
A Beach – Female 62
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
67
42
25
11
3
138
18
24
20
185
Day 28
69
44
25
99
57
291
460
572
407
395
R Range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Phen
Clinical details
• Ankylosing spondylitis
• RUQ Pain, anorexia, weight loss, itch, dark urine
• Rx phenylbutazone
Dunk I Land - Male 26
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
78
40
38
98
65
120
981
1933
253
473
Day 2
84
44
40
79
45
125
770
1635
264
366
Day 5
83
42
41
43
24
109
329
878
253
223
Day 8
83
43
40
27
14
112
134
462
227
160
Day 14
82
44
38
21
11
94
50
153
152
155
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Clinical details
• IV drug user
• Alcohol abuse
• ?Paracetamol
Gordon Vale – Male 27
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
40
28
4
1
64
20
14
8
241
Day 9
39
36
6
<1
240
210
401
130
522
R.range
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
EB
Gordon Vale – Male 27
Haemoglobin Haematocrit
MCV MCH
Red Cell count WCC
Neutrophils Lymphocytes
Monocytes Eosinophils Basophils
Atyp. Lymphs ESR
Platelets IM Serology
Day 1 120 0.37
93 30.5
3940.0 4.8
3.08 0.95 0.63 0.10 0.04
7
151
Day 9 137 0.43
93 29.4
4660.0 11.4 3.19 5.81 0.57 0.11
1.71
21
Pos
R.range 115-155
0.35-0.47 81-98
27.5-34.0 3900.0-5600
3.5-12.0 1.50-8.00 1.20-4.00 0.00-0.90 0.00-0.60 0.00-0.15
1-12
150-400
Gordon Vale – Male 27
Microbial Serology
CMV IgG
CMV IgM
IM Screen
EBV IgG
EBV IgM
EBNA IgG
Parvovirus IgG
Parvovirus IgM
Day 1
Neg
Neg
Neg
Neg
Neg
Pos
Pos
Day 9
Pos
Pos
Pos
Neg
Charlie Ville - Male 54
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LDH
Day 1
79
47
32
15
4
63
55
41
644
165
R.range
63-80
35-50
20-40
3-20
0-7
30-115
5-40
5-40
5-65
100-225
Maree Bar – Female 69
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
66
42
24
6
2
103
17
19
78
560
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Gay N Dah – female 79
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
66
35
31
38
10
78
47
19
25
358
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225 per
Gay N Dah
Hb 86 g/L
Red Ferne - Male 57
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
70
37
33
30
<1
95
96
19
80
965
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Red Ferne
CK 42580 U/L
Edward River – Male 67
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
66
42
24
6
2
1380
17
19
78
185
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Bill – Male 57
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
56
33
23
14
5
966
25
24
28
285
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Bill
PSA 150 U/L (<6.5)
Brad Field – Male 77
Total
Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Calcium
Phosphate
54
33
21
18
6
366
15
14
68
185
3.9
5
0.6
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
2.10-2.55
0.9-1.5
Hugh N Dene
18 months old
Hx - ?viral disease
Hugh N Dene
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
76
42
34
6
2
9380
7
9
22
185
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
75
50
25
44
7
126
23
20
17
153
R.range
60-75
35-50
20-40
3-20
<7
60-300
20-60
5-40
5-65
100-290
Blair Athol - Male 15
Armac - Male 57
Total Protein
Albumin
Globulins
Total Bili
Conj Bili
Alk Phos
AST
ALT
Gamma GT
LD
Day 1
55
25
30
278
168
155
98
87
356
290
R.range
63-80
35-50
20-40
3-20
<7
30-115
5-40
5-40
5-65
100-225 Cir
Clinical details
• Alcohol abuse
• Malnutrition
Date 29/01 28/04 14/05 02/07 Units Range S BILI 38* 29* 27* 34* umol/L (2-20) S ALP 234* 192* 206* 193* U/L (30-120) S GGT 93* 83* 87* 74* U/L (5-45) S ALT 124* 137* 113* 103* U/L (5-40) S AST 187* 202* 167* 166* U/L (5-40)
Ana Kie Female DOB 30/1/1934
Are any of these results different to the previous?
Date 29/01 28/04 14/05 02/07 Units Range S BILI 38 29 27 34 umol/L (2-20) S ALP 234 192 206 193 U/L (30-120) S GGT 93 83 87 74 U/L (5-45) S ALT 124 137 113 103 U/L (5-40) S AST 187 202 167 166 U/L (5-40)
Ana Kie Female DOB 30/1/1934
Are any of these results different to the previous?
Some results are analytically different,
CDA
4 25 8 12 15
Date 29/01 28/04 14/05 02/07 Units Range S BILI 38 29 27 34 umol/L (2-20) S ALP 234 192 206 193 U/L (30-120) S GGT 93 83 87 74 U/L (5-45) S ALT 124 137 113 103 U/L (5-40) S AST 187 202 167 166 U/L (5-40)
Ana Kie Female DOB 30/1/1934
Are any of these results different to the previous?
Some results are analytically different, But none are clinically different.
CDA
4 25 8 12 15
CDT
23 44 33 81 61
Date 29/01 28/04 14/05 02/07 Units Range S BILI 40 30 30 35 umol/L (2-20) S ALP 250 200 200 200 U/L (30-120) S GGT 95 85 90 75 U/L (5-45) S ALT 120 140 110 100 U/L (5-40) S AST 190 200 170 170 U/L (5-40)
Ana Kie Female DOB 30/1/1934
All are biologically the same.
No significant changes.
Program
• Blood Gases
Abnormally low pH (high H+)
H+ + HCO3 <=>H2CO3
<=>H2O + CO2
Acidosis
pH = pKa + log(HCO3 /H2CO3) = pKa + log(HCO3 /apCO2)
Acidosis
Other Buffers Phosphate Albumin - binding of calcium Haemoglobin
histidine
Respiratory - increased pCO2 Metabolic - decreased HCO3
Acidosis
Respiratory - decreased pCO2 Metabolic - increased HCO3
Alkalosis
Respiratory - fast, breathing rate Metabolic - slow, renal changes
Compensation - pH
Theo Dore pH 7.34 (7.35-7.45)
pO2 55 mmHg (80 – 110)
pCO2 70 mmHg (35-45)
HCO3 45 mmol/L (23-33)
Respiratory - primary pCO2 Metabolic - compensation HCO3
Respiratory Acidosis
Respiratory Acidosis CNS Trauma, infection, tumour Sedatives, narcotics Myopathies Obstruction Lung Disease
Belle N Den pH 7.29 (7.35-7.45)
pO2 52 mmHg (80 – 110)
pCO2 53 mmHg (35-45)
HCO3 36 mmol/L (23-33)
E.C. Patient
COAD Chest infection Treatment?
Belle N Den
pH 7.20 (7.35-7.45)
pO2 65 mmHg (80 – 110)
pCO2 100 mmHg (35-45)
HCO3 40 mmol/L (23-33)
Ema Sleigh pH 7.44 (7.35-7.45)
pO2 105 mmHg (80 – 110)
pCO2 30 mmHg (35-45)
HCO3 20 mmol/L (23-33)
Respiratory Alkalosis CNS Trauma, infection, tumour Drugs - salicylates Anxiety Septicaemia Artificial ventilation
Hinch N Brook
pH 7.58 (7.35-7.45)
pO2 52 mmHg (80 – 110)
pCO245 mmHg (35-45)
HCO3 41 mmol/L (23-33)
v
Metabolic - primary increased HCO3 Respiratory - compensating increase pCO2
Metabolic Alkalosis
Metabolic Alkalosis HCO3 loss of HCl - GI renal loss of H+ - aldo infusion of base
citrate, bicarbonate, lactate
ingestion of base
Em R Alde- 26 male
pH 7.06 (7.35-7.45)
pO2 115 mmHg (80 – 110)
pCO2 20 mmHg (35-45)
HCO3 5 mmol/L (23-33)
Metabolic Acidosis • H+ load
• H+ secretion
• Loss of base
Robinson Gorge pH 7.01 (7.35-7.45)
pO2 43 mmHg (80 – 110)
pCO2 68 mmHg (35-45)
HCO3 16 mmol/L (23-33)
Combined Acidosis Cardiac Arrest Lactic acidosis Respiratory acidosis
Mary Borough pH 7.43 (7.35-7.45)
pO2 65 mmHg (80 – 110)
pCO2 75 mmHg (35-45)
HCO3 46 mmol/L (23-33)
Metabolic alkalosis + respiratory acidosis Diuretic therapy + COAD
Clinical use Quality control
Anion Gap
Anion gap = sum of unmeasured anions = measured cations - measured anions = Na (+ K) - HCO3 - Cl
Anion gap ketoacids - DM lactic acidosis other organic acids - renal disease poisons
Drug Causes of Acidosis methanol ethanol salicylate ethylene glycol paraldehyde use of Osmolar Gap
Other causes of abnormal AG
Lithium Protein - albumin
- globulin
Error with Anion gap SD2 = SDNa
2 + SDHCO32 + SDCL
2
SD approximately 2 mmol/L thus error is +/- 4! RR 5-15
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Urea
Creatinine
139
4.9
96
6
37
26.4
0.34
135-145
3.5-4.5
100-110
24-32
5-15
<7.5
<0.12
Hervey Bay
Tissue Anoxia Circulatory collapse Lactic acidosis l-lactate d-lactate - gut resection
Jeri Coe
Epileptic
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Calcium
Phosphate
Urea
Glucose
T.Protein
T.Bilirubin
ALP
ALT
GGT
140
3.6
115
28
- 3
2.27
1.2
5.4
4.9
76
9
49
15
88
135-145
3.5-4.5
100-110
24-32
5-15
2.10-2.55
0.9-1.5
<7.5
<8.0
62-80
<20
<115
<40
<60
Di Sart
renal transplant
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Calcium
Phosphate
Urea
Creatinine
T.Protein
T.Bilirubin
ALP
ALT
GGT
139
2.9
116
11
12
2.27
1.2
3.4
0.14
67
9
249
22
28
135-145
3.5-4.5
100-110
24-32
5-15
2.10-2.55
0.9-1.5
<7.5
<0.12
62-80
<20
<115
<40
<60
• Renal Tubular Acidosis
Urine pH>5.5 Inability to secrete H+
Inability to conserve HCO3
Aldosteronism
Renal Tubular Acidosis Tubular defects Inherited, autoimmune,toxins metals, drugs, antibodies, proteins.
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Calcium
Phosphate
Urea
Creatinine
142
5.9
102
16
24
1.98
2.6
27.3
0.79
135-145
3.5-4.5
100-110
24-32
5-15
2.10-2.55
0.9-1.5
<7.5
<0.13
Ye Poon
Renal Failure Tubular disease - H+, HCO3
Failure to secrete acids – SO4, PO4, organic acids
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Urea
Creatinine
pH
138
2.8
114
13
11
2.0
0.10
7.29
135-145
3.5-4.5
100-110
24-32
5-15
<7.5
<0.13
dia
Du Aringa
Loss of Base Diarrhoea - severe Potassium loss
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Calcium
Phosphate
Urea
Glucose
131
6.6
89
6
36
2.27
2.2
15.4
54.9
135-145
3.5-4.5
100-110
24-32
5-15
2.10-2.55
0.9-1.5
<7.5
<8.0
Mor Ven
Diabetic Ketoacidosis ketone production dehydration - osmotic ??Potassium loss despite K+ lactic acidosis - circulatory
Program
• Electrolytes
Mon Toe 83
Bedridden
Comatose
Previous rapid mental deterioration
Mon Toe
Sodium 164 mmol/L (135-145)
Potassium 3.3 mmol/L (3.5-5.0)
Chloride 122 mmol/L (96-109)
Urea 20.6 mmol/L (3.5-7.5)
Creatinine 0.21 mmol/L (0.04-0.12)
Osmolality 368 mmol/kg (267-294)
dh
Sodium
Potassium
Chloride
Bicarbonate
Urea
Creatinine
150
4.5
117
25
9.1
0.14
135-145
3.5-4.5
100-110
24-32
<8.0
0.06-0.12
di
Tam Boe
Tam Boe
Urine
Osmolality 220 mmol/kg
Sodium
Potassium
Chloride
Bicarbonate
Glucose
Calcium
Phosphate
Urea
Creatinine
159
4.4
119
27
46.0
2.05
1.6
17.2
0.18
135-145
3.5-4.5
100-110
24-32
<8.0
2.10-2.55
0.9-1.5
<7.5
<0.13
hodc
T A Room
Diabetes
Osmotic diuresis
Hyperosmolar coma
dehydration + lactate
M T Morgan - 64
Recent history –
Disorientation
Confusion
M T Morgan Sodium 116 mmol/L (135-145)
Potassium 4.7 mmol/L (3.5-5.0)
Bicarbonate 25 mmol/L 923-32)
Urea 3.2 mmol/L (3.5-7.5)
Osmolality 233 mmol/kg (267-294)
M T Morgan Urine
Sodium 113 mmol/L
Potassium 52 mmol/L
Osmolality 698 mmol/kg
Sodium
Potassium
Chloride
Bicarbonate
Glucose
Phosphate
123
7.8
83
7
36.0
2.1
135-145
3.5-4.5
100-110
24-32
<5.5
0.9-1.5
Ing Ham
Diabetic ketoacidosis Osmotic diuresis Ketosis Na loss K release cells Dehydration Catabolism P
Sodium
Potassium
Chloride
Bicarbonate
Urea
Creatinine
150
2.8
90
37
23.2
0.20
135-145
3.5-4.5
100-110
24-32
<8.0
0.06-0.12
Mun Gana
Sodium
Potassium
Chloride
Bicarbonate
Urea
Creatinine
128
2.1
79
40
3.2
0.12
135-145
3.5-4.5
100-110
24-32
<8.0
0.06-0.12
Woora Binda
Vomiting
• Na/Cl loss • Alkalosis - loss of acid • Dehydration - Fluid Replacement?
Sodium
Potassium
Chloride
Bicarbonate
Urea
Creatinine
122
6.8
88
17
13.2
0.14
135-145
3.5-4.5
100-110
24-32
<8.0
0.06-0.12
ad
Fraser Island
Adrenal Disease
Addison’s
Lack of Aldosterone
Na loss
Water loss
Dehydration/renal failure
Sodium
Potassium
Chloride
Bicarbonate
Anion Gap
Urea
Creatinine
145
1.7
85
40
20
2.4
0.08
135-145
3.5-4.5
100-110
24-32
5-15
<7.5
<0.12
con
Lady Musgrave
Program
• Other
Mutta Burra Anorexia
Pain
Thirst
Vomiting
Mutta Burra
Creatinine 0.44 mmol/L (0.04 – 0.12)
Calcium 3.82 mmol/L (2.10-2.60)
PTH <2 ng/L (6 - 40)
25 OH Vitamin D 850 nmol/L (70-150)
23/08 17/09
Sodium 144 142 mmol/L (135 - 145)
Potassium 4.3 4.2 mmol/L (3.5 - 5.0)
Chloride 105 101 mmol/L (96 - 109)
Bicarbonate29 28 mmol/L (23 - 32)
Anion Gap 10 13 mmol/L (5 - 15)
Calcium (corr) 1.55 1.73 mmol/L (2.10 - 2.60)
Phosphate 1.8 1.6 mmol/L (0.8 - 1.5)
Creatinine 0.10 0.10 mmol/L (0.04 - 0.12)
Glucose 4.2 4.6 mmol/L (3.6 - 7.7)
Calc Osmo 287 283 mmol/kg (267 - 294)
T Bili 15 13 umol/L (3 - 20)
AST 29 32 U/L (< 40)
ALT 21 24 U/L (< 40)
GGT 14 13 U/L (5 - 65)
LD 274 216 U/L (100 - 225)
Clare Mont- 43 yr old male OPD
Additional Investigations
PTH <2 ng/L 6-40
25 OH Vit D 126 nmol/L 35-150
FT4 19 pmol/L 9-25
Sodium 139 mmol/L (135 - 145)
Potassium 4.1 mmol/L (3.5 - 5.0)
Chloride 98 mmol/L (96 - 109)
Bicarbonate15 mmol/L (23 - 32)
Anion Gap 26 mmol/L (5 - 15)
Calcium (corr) 2.57 mmol/L (2.10 - 2.60)
Phosphate 4.7 mmol/L (0.8 - 1.5)
Creatinine 0.14 mmol/L (0.04 - 0.12)
Glucose 17.6 mmol/L (3.6 - 7.7)
Calc Osmo 291 mmol/kg (267 - 294)
T Bili 6 umol/L (3 - 20)
ALP 81 U/L (30 - 115)
AST 277 U/L (< 40)
ALT 253 U/L (< 40)
GGT 91 U/L (5 - 65)
LD 384 U/L (100 - 225)
CK 217 U/L (10 - 200)
Sarina - 22yr old male, ICU, unconscious
Hb 144 g/L (135-175) Hct 0.43 (0.40-0.54) RCC 4.4 10^12/L (4.5-6.5) MCV 97 fL (80-100) WCC 13.9 10^9/L (3.5-10.0) Neutrophils 9.70 10^9/L (1.5-6.5) Lymphocytes 3.60 10^9/L (1.0-4.0) Monocytes 0.50 10^9/L (0-0.9) Eosinophils 0.10 10^9/L (0-0.6) Basophils 0.00 10^9/L (0-0.15) Platelets 236 10^9/L (150-400)
22yr old male, ICU
Haemolytic Studies
Plasma Haemoglobin Detected
Coagulation Studies All Normal
(INR, PT, APTT, Platelet Count, Fibrinogen)
22yr old male, ICU
Urine Drug Screen R-U-Creatinine 0.6 mmol/L Methadone Met Not Detected Benzodiazepines Present Opiates Not Detected Sympathomimetic amines Not Detected Cannabinoids Not Detected Cocaine Metabolite Not Detected Barbiturates Not Detected
S-Salicylate Not Detected
S-Paracetamol Not Detected
S-Alcohol Not Detected
22yr old male, ICU
14/1 15/1
1920 1615
Sodium 139 152 mmol/L (135 - 145)
Potassium 4.1 5.3 mmol/L (3.5 - 5.0)
Chloride 98 121 mmol/L (96 - 109)
Bicarbonate 15 17 mmol/L (23 - 32)
Anion Gap 26 14 mmol/L (5 - 15)
Calcium (corr) 2.57 2.25 mmol/L (2.10 - 2.60)
Phosphate 4.7 0.9 mmol/L (0.8 - 1.5)
Creatinine 0.14 0.09 mmol/L (0.04 - 0.12)
Glucose 17.6 7.0 mmol/L (3.6 - 7.7)
Calc Osmo 291 307 mmol/kg (267 - 294)
T Bili 6 13 umol/L (3 - 20)
AST 277 142 U/L (< 40)
ALT 253 306 U/L (< 40)
GGT 91 126 U/L (5 - 65)
LD 384 378 U/L (100 - 225)
22yr old male, ICU
S-Osmolality 316 mmol/kg (280 - 297)
(Measured by freezing point depression)
Calc. Osmolality 291 mmol/kg (280 - 297)
(Osmolar gap 25 mmol/L)
S-Lactate 17.3 mmol/L (0.6 - 1.8)
Common Findings in Submersion/Drowning
Neurological insult - brain failure or impairment
Hypoxia and pulmonary damage 10-20% may however maintain dry lungs
Multiple organ damage Lungs - water aspiration - loss of surfactant and normal
gaseous exchange
Other - hypoxemia, ischaemia, acidosis
Intravascular haemolysis Particularly fresh water cases
Recommended