Question

Patient is a 68 year old male with hx of CVA (no residuals), HTN, IDDM (type 2), COPD, asthma, CHF, CKD (stage 3), last seen in the ED on 10/4/20 for evaluation of altered mental status. He was admitted with dx of right foot gangrene. He was discharged in 10/20/20. On 10/22/20 the patient presented to ED again via AMR from restorative care center for complaints of SOB, hypoxia, and was found to have evidence of pneumonia. He was placed on oxygen 2L via nasal cannula at facility with O2 sat in the 80's. Started on diuretics. Pt was downgraded on 10/29, upgraded on 10/31 due to acute hypoxic hypercapnic respiratory failure and increasing anemia (hgb <7).

Physical findings: Pt is 253 lbs. VSS. On telemetry reading 109-111 HR. Falls precaution. Bedside commode with assist. Scrotal swelling. Skin is cool, dry; 2+ bilateral LE edema, bilateral lower extremity cellulitis, right lower extremity wound--  pressure ulcer to right heel extending unto left posterior ankle with good granulation tissue, no purulent drainage; pressure ulcer to left posterior calf with good granulation tissue, also no purulent drainage. Dressings changed per orders. On q2hr turn. Respirations labored. Crackles to all lobes, decreased breath sounds to right lower lobe. Pt has intermittent coughing, small, clear sputum (uses yankauer suction independently). Encouraging pt to deep breathe and cough. On consistent carb diet (chopped).

Medications:

Budenoside INH

Novolog Flx Pen (None were administered throughout shift; providers parameter)

Levalbuterol HCL Nebulizer

Tamsulosin HCL PO daily

Potassium Chloride PO daily

Furosemide IV daily

Levoflaxicin PO Q48hr

Guaifenesin PO BID

Pantoprazole PO BID

Zinc Oxide 1 applic. TP BID to sacrum

Febuxostat PO daily

Nystatin PO QID (swish and swallow)

Labs: (only noted the abnormal)

WBC: 3.16L

Hgb: 8.0L

Hct: 27.1L

MCH: 25.3L

MCHC: 29.5L

RDW: 19.9H

Neutrophils: 74.9H

Lymph: 12.3L

Mono: 10.6H

ABG PO2: 78L

BUN: 42H

Creatinine: 1.95H

AfAM 40L

NonAfAM 34L

Glucose: 166H (Average: providers parameter)

Calcium: 8.4L

Platelet count: 292 (normal)

Question:

- Labs: (discussed how the labs relates to the patient’s specific condition).

Answer 1

Relation of lab findings with patients condition :

WBC 3.16L-

A low white blood cell count usually is caused by:

Viral infections that temporarily disrupt the work of bone marrow

Certain disorders present at birth (congenital) that involve diminished bone marrow function

Cancer or other diseases that damage bone marrow

Autoimmune disorders that destroy white blood cells or bone marrow cells

Severe infections that use up white blood cells faster than they can be produced

Medications, such as antibiotics, that destroy white blood cells

Sarcoidosis (collections of inflammatory cells in the body).

Hgb 8L-

A low hemoglobin level is referred to as anemia or low red blood count. A lower than normal number of red blood cells is referred to as anemia and hemoglobin levels reflect this number. There are many reasons for anemia.

Some of the more common causes of anemia are:

loss of blood (traumatic injury, surgery, bleeding, colon cancer, or stomach ulcer),

nutritional deficiency (iron, vitamin B12, folate),

bone marrow problems (replacement of bone marrow by cancer),

suppression by red blood cell synthesis bychemotherapy drugs,

kidney failure

abnormal hemoglobin structure (sickle cell anemia or thalassemia

HCT 27.1L-

A lower than normal hematocrit can indicate an insufficient supply of healthy red blood cells (anemia) A large number of white blood cells due to long-term illness, infection or a white blood cell disorder such as leukemia or lymphoma. Vitamin or mineral deficiencies. Recent or long-term blood loss.

MCH 25.3L-

The normal values for MCH are 29 ± 2 picograms (pg) per cell.

low MCH value typically indicates the presence of iron deficiency anemia. Iron is important for the production of hemoglobin. The body absorbs a small amount of iron that is eaten in order to produce hemoglobin.

MCHC 29.5L-

MCHC indicates the amount of hemoglobin per unit volume. In contrast to MCH, MCHC correlates the hemoglobin content with the volume of the cell. It is expressed as g/dl of red blood cells or as a percentage value. The normal values for MCHC are 34 ± 2 g/dl.

The most common cause of low MCHC is anemia. Hypochromic microcytic anemia commonly results in low MCHC. This condition means the red blood cells are smaller than usual and have a decreased level of hemoglobin. This type of microcytic anemia can be caused by lack of iron.

RDW: 19.9H-

A normal range for red cell distribution width is 12.2 to 16.1 percent in adult females and 11.8 to 14.5 percent in adult males.

If the RDW is too high, it could be an indication of a nutrient deficiency, such as a deficiency of iron, folate or vitamin B-12. These results could also indicate macrocytic anemia, when body doesn't produce enough normal red blood cells and the cells it does produce are larger than normal.

ABG PO2: 78L-

An acceptable normal range of ABG values of 75-100 mmhg. So it's normal.

BUN: 42H-

7 to 20 mg/dL (2.5 to 7.1 mmol/L) is considered normal range of BUN.

high BUN value can mean kidney injury or disease is present. Kidney damage can be caused by diabetes or high blood pressure that directly affects the kidneys. High BUN levels can also be caused by low blood flow to the kidneys caused by dehydration or heart failure. Many medicines may cause a high BUN.

Creatinine: 1.95H-

The normal range for creatinine in the blood may be 0.84 to 1.21 milligrams per deciliter.

If creatine level increase is caused by a kidney issues, it causes symptoms. Kidney conditions often cause bladder and fluid retention issues. If your kidneys aren't working well enough to remove toxins and waste from your body, you could notice a wide range of symptoms, including Nausea

Glucose: 166H -

A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal.

Hyperglycemia is a defining characteristic of diabetes when the blood glucose level is too high because the body isn't properly using or doesn't make the hormone insulin. Eating too many processed foods may cause blood sugar to rise.

Calcium: 8.4L-

Sustained low calcium levels in blood may confirm a diagnosis of calcium deficiency disease. Normal calcium levels for adults can range from 8.8 to 10.4 milligrams per deciliter (mg/dL). There may be at risk for calcium deficiency disease if your calcium level is below 8.8 mg/dL.

Platelet count: 292 (normal)-Platelet count is the number of platelets in the blood. A normal platelet count ranges from 150,000 to 350,000.