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