P5.1.1B.EvidenceReport1F

Project 5.1.1B Evidence Report #1

General Lab Tests

Blood work

Lab: Auto Differential

Test Abbrev:

Test Full Name:

Purpose of Test:

Normal Range:

Result:

Patient 1

Result:

Patient 2

Result:

Patient 3

Result:

Patient 4

Result:

Patient 5

Neutro %

Percentage of Neutrophils

Percent of neutrophils in the blood.

40% - 60%

62%

70%

60%

64%

56%

Lymph %

Percentage of Lymphocytes (T cells and B cells)

Percent of lymphocytes in the blood.

20% - 40%

35%

25%

33%

30%

40%

Mono %

Percentage of Monocytes

Percent of Monocytes in the blood.

2% - 8%

2%

3%

5%

4%

2%

Eosinophil %

Percentage of Eosinophils

Percent of Eosinophils in the blood.

1% - 4%

0.5%

1.3%

1.5%

1%

1.1%

Baso %

Percentage of Basophils

Percent of basophils in the blood.

0.5% - 1%

0.5%

0.7%

0.5%

1%

0.9%

Lab: Complete Blood Count

Test Abbrev:

Test Full Name:

Purpose of Test:

Normal Range:

Result:

Patient 1

Result:

Patient 2

Result:

Patient 3

Result:

Patient 4

Result:

Patient 5

WBC

White Blood Cell Count

Measures the number of WBCs. Elevated levels might indicate an infection or allergic reaction.

4,500 – 10,000 cells/mcL

17,000

68,000

15,600

9,400

21,000

RBC

Red Blood Cell Count

Measures the number of RBCs to help diagnose anemia and other conditions affecting RBCs.

Males: 4.7 – 6.1 million cells/mcL

Females: 4.2 – 5.4 million cells/mcL

5.0

5.0

4.9

5.7

4.7

Hgb

Hemoglobin

Measures the amount of hemoglobin in the blood.

Males: 13.8 – 17.2 gm/dL

Females: 12.1 – 15.1 gm/dL

15

10

14

16

12

Hct

Hematocrit

Measures the percentage of RBCs found in whole blood.

Males: 40.7% - 50.3%

Females: 36.1% - 44.3%

52%

62%

54%

60%

47%

Platelet

Platelet Count

Measures how many platelets are in the blood.

150,000 - 400,000 platelets/mcL

100,000

60,100

120,000

140,000

89,000

Lab: Comprehensive Metabolic Panel

Test Abbrev:

Test Full Name:

Purpose of Test:

Normal Range:

Result:

Patient 1

Result:

Patient 2

Result:

Patient 3

Result:

Patient 4

Result:

Patient 5

Glucose Level

Glucose Level

Measures the amount of glucose in the blood.

< 100 mg/dL

67

88

70

72

72

BUN

Blood Urea Nitrogen

Measures the amount of urea nitrogen in the blood.

7 - 20 mg/dL

21

32

19

18

24

Creatinine, Serum

Creatinine, Serum

Measures the amount of creatinine in the liquid part of the blood.

0.8 to 1.4 mg/dL

2.0

2.5

1.4

1.3

1.8

GFR

Glomerular Filtration Rate

Estimates how much blood passes through the tiny filters in the kidneys, called glomeruli, each minute.

90 - 120 mL/min

95

97

100

90

110

Calcium

Calcium

Measures the total amount of calcium in the blood.

8.5 to 10.2 mg/dL

8.9

8.2

10.0

9.0

8.1

Protein Level

Total Protein Level

Rough measure of all the proteins found in the fluid portion of your blood. Specifically looks at the total amount of two classes of proteins: albumin and globulin.

6.0 to 8.3 gm/dl

5.0

4.9

6.0

5.9

5.5

Albumin Level

Albumin Level

Measures the amount of albumin (a protein made by the liver) in the clear liquid portion of the blood.

3.4 - 5.4 g/dL

3.6

3.0

3.1

3.2

3.3

TBil

Total Bilirubin

Measures bilirubin (a fluid produced by the liver) in the blood.

0.3 to 1.9 mg/dL

0.6

1.2

1.0

1.5

0.8

AST

Aspartate Aminotransferase

Measures the amount of AST (an enzyme) in the blood.

10 to 34 IU/L

11

11

15

33

31

ALT

Alanine Transaminase

Measures the amount of ALT in the blood.

7 – 40 IU/L

15

34

31

22

21

Alk Phos

Alkaline Phosphatase

Measures the level of alkaline phosphatase in the blood.

44 to 147 IU/L

56

76

87

48

49

Sodium

Sodium (Na+)

Measures the concentration of sodium in the blood.

135 to 145 mEq/L

136

138

147

140

140

Potassium

Potassium (K+)

Measures the amount of potassium in the blood.

3.7 to 5.2 mEq/L

4.0

4.3

3.8

3.9

5.0

Chloride

Chloride

Measures the amount of chloride in the fluid portion (serum) of the blood

96 - 106 mEq/L

100

98

96

105

98

CO2

Carbon Dioxide

Measures the level of bicarbonate in the blood.

20-29 mEq/L

25

25

22

27

21

Lab: Lipid

Test Abbrev:

Test Full Name:

Purpose of Test:

Normal Range:

Result:

Patient 1

Result:

Patient 2

Result:

Patient 3

Result:

Patient 4

Result:

Patient 5

Cholesterol

Total Cholesterol

Measures all the cholesterol and triglycerides in the blood.

Desirable: Under 200 milligrams per deciliter (mg/dL)

Borderline high: 200 to 239 mg/dL

High risk: 240 mg/dL and higher

185

170

205

220

159

Triglycerides

Triglycerides

Measures the amount of triglycerides in the blood.

Normal: <50

High: >200

70

55

89

42

40

HDL

High-Density Lipoprotein Test

Measures the level of HDL cholesterol in the blood.

Males high risk: < 37 mg/dL

Females high risk: <47 mg/dL

Low risk: > 59

56

65

78

35

50

LDL

Low-Density Lipoprotein Test

Measures the level of LDL cholesterol in the blood.

Optimal: Less than 100 mg/dL

Near Optimal: 100 - 129 mg/dL

Borderline High: 130 - 159 mg/dL

High: 160 - 189 mg/dL

Very High: 190 mg/dL and higher

103

90

100

125

89

Lab: Additional Blood Tests

Test Abbrev:

Test Full Name:

Purpose of Test:

Normal Range:

Result:

Patient 1

Result:

Patient 2

Result:

Patient 3

Result:

Patient 4

Result:

Patient 5

TSH, High Sensitivity

Thyroid Stimulating Hormone

Measures the amount of TSH in the blood.

0.4 - 4.0 mIU/L

3.0

0.9

3.2

2.4

2.0

LDH,

Lactate Dehydrogenase

Measures the amount of LDH in the blood.

105-133 IU/L

145

245

180

142

130

PT

Prothrombin Time

Tests time for plasma to clot.

11 - 14 seconds

17

18

15

15

18

PTT

Partial Thromboplastin Time

Tests time for blood to clot.

25 - 35 seconds

35

44

30

35

40

Urinalysis

Macroscopic Analysis

Color:

Clarity (transparency):

Normal urine should be a shade of yellow ranging from a straw to amber color.

Abnormal urine can be colorless, dark yellow, orange, pink, red, green, brown, or black.

Normal urine should be clear.

Abnormal urine can be hazy, cloudy, or turbid.

Chemical Analysis

Test:

Normal Results:

Leukocytes

Normal urine does not contain leukocytes.

Nitrite

Normal urine does not contain nitrites.

Urobilinogen

Normally present in urine in low concentrations. It is formed in the intestine from bilirubin, and a portion of it is absorbed back into the bloodstream.

Protein

Normal urine levels of proteins (called albumin) are very small, usually approximately 0 to 8 mg/dl.

pH

Test measures whether urine is acidic, basic, or neutral. Normal urine ranges from 4.6 to 8.0.

Blood

Normal urine does not contain blood.

Specific Gravity

Test measures the concentration of particles in the urine and evaluates the body’s water balance. The more concentrated the urine, the higher the urine-specific gravity. The most common increase in urine-specific gravity is the result of dehydration. Normal urine ranges between 1.002 to 1.028

Ketones

Normal urine does not contain ketones, the endpoint of rapid or excessive fat breakdown, in the urine.

Bilirubin

Normal urine does not contain bilirubin, a fluid produced by the liver.

Glucose

Normal urine does not contain glucose.

Microscopic Examination

Microscopic examination of urine was normal for all patients except for Patient 2. Red blood cells, leukocytes, and some calcium oxalate crystals were observed in the urine sample. A trace amount of red blood cells was detected in the urine of Patient 3 and trace amount of leukocytes were present in the urine of Patient 5.

Normal:

Abnormal:

Presence of epithelial cells, as they are the cells that line the urinary tract.

Presence of a few crystals, including calcium oxalate, triple phosphate crystals, and amorphous phosphates.

Presence of red blood cells.

Presence of white blood cells and bacteria, signs of infections.

Presence of a large number of crystals, or certain types of crystals, may mean kidney stones are present or there is a problem with how the body is using food.

Clinical Exam Results

Patient Vital Signs

* Values displayed are the average value over a 24-hour period

Patient 1

Patient 2

Patient 3

Date

5/17

5/19

5/21

Date

5/15

5/16

5/17

Date

5/1

5/3

5/4

BP

120/84

90/ 70

80/ 60

BP

118/70

110/65

80/ 60

BP

100/74

100/60

85/ 60

Pulse

90

110

80

Pulse

110

105

98

Pulse

75

120

118

Resp

22

22

27

Resp

24

26

30

Resp

20

21

25

Temp

103

103

99

Temp

103

102

100

Temp

102

104

100

Patient 4

Patient 5

Date

5/19

5/20

5/21

Date

5/25

5/26

5/27

BP

140/90

148/100

100/85

BP

90/ 70

80/ 60

72/ 50

Pulse

90

125

120

Pulse

80

110

105

Resp

24

28

30

Resp

23

25

28

Temp

101

100

102

Temp

104

103

100

Chart Notes

Due to high WBC counts, all patients were administered broad-spectrum antibiotics.

Patient 1

By second day of admission, patient experiences shortness of breath. By the end of the day, patient shows signs of acute respiratory distress and requires mechanical ventilation. Girlfriend shows similar disease progression – suspected person to person transmission.

Patient 2

On third day of admission, patient begins coughing up yellow sputum with occasional traces of blood. Oxygen saturation steadily decreases as the patient notes increased difficulty breathing. Infection is not responding to antibiotics.

Patient 3

The patient’s fever begins to subside; however, patient now complains of severe nausea and is experiencing frequent vomiting. Patient is extremely fatigued and dizzy and passes in and out of consciousness. Renal function begins to decline. Physical exam reveals several infected skin lesions.

Patient 4

Patient shows severe tachypnea. Fever remains high and the patient complains of nausea. The patient complains of chest pain and overall muscle weakness and has developed a dry cough. Supplemental oxygen administered.

Patient 5

The patient experiences vomiting and diarrhea. Blood pressure continues to drop, as does heart rate. A cough begins to develop on the sixth day of admission. Oxygen saturation dips below 90. Intubation may be necessary. Rash detected on arm. No evidence of animal bites.

Heart Studies

Because of declining heart rate and apparent hypotension, a cardiac workup was ordered for all five patients. EKG and echocardiogram results are found below.

EKG

The diagram below displays a normal EKG (electrocardiogram). An EKG is a graphical recording of the electrical events occurring within the heart.

· The P wave represents the start of the electrical journey as the impulse spreads from the sinoatrial node downward from the atria through the atrioventricular node and to the ventricles.

· The QRS complex represents ventricular activation.

· The T wave results from ventricular repolarization, which is a recovery of the ventricular muscle tissue to its resting state.

Patients 1, 2, 3, and 5 all showed EKG results similar to those shown below.

Patient 4 presented with the EKG tracing shown at this link. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cardio&part=A39&rendertype=figure&id=A119

Echocardiogram

In an echocardiogram, ultrasound or sound waves are used to monitor blood flow in the heart and create a moving picture. Doctors can monitor blood movement through the valves and measure overall blood flow to and from the chambers.

Echocardiogram confirms decreased cardiac output in Patients 1, 2, and 4. Cardiac function is depressed and cardiac output does not seem to respond to the fluid challenge.

EMG

Each patient complained of some type of muscle weakness, soreness, or pain. An electromyography, EMG, was performed on all of the patients to check the health of the muscles and the nerves that control the muscles. Thin needle electrodes were placed through the skin into patients’ affected muscles, which picked up the electrical activity given off by the muscles. The EMGs were conducted with repetitive stimulation at 20 - 50 Hz. Once the electrodes were in place, the patients were asked to contract the affected muscles. All five patients’ EMGs showed results in the normal range.

Imaging Results

Because of patient shortness of breath and tachypnea, lung studies were ordered for all five patients. A normal chest x-ray is shown below. Darker shadows represent the air-filled lungs. Solid, dense, or fluid-filled structures appear white.

All Patients showed similar lung films. Scans from Patient 2 are displayed for analysis. Compare both the initial and repeat scan to the normal chest x-ray and note any differences on the Evidence Log.

Initial scan – 2 days post admission

Heart size appears normal. Scan shows minimal changes of interstitial pulmonary edema.

Repeat scan – 3 days post admission

Heart size appears normal. Scan shows interstitial edema progressing to alveolar edema. Progression is rapid. Pleural effusions are visible.

Pathology Report

A patient admitted last week died of similar symptoms. Relevant findings from the autopsy report are described below.

Internal organs appear normal. Changes are visible in the lungs. Grossly, the lungs are dense, rubbery, and heavy, usually weighing twice as much as the average lung. They are often found floating in a pool of yellow serous fluid within the pleural cavity.

Obtain a microscope slide of normal lung tissue from your teacher. View the slide under the microscope. Draw what you see. Note the appearance of the alveoli, the air sacs.

Compare what you see in the normal slide to the patient tissue sample shown below in the low power photomicrograph. Describe any differences in the Evidence Log.

No evidence of viral pneumonia or of common bacteria and viruses that attack the lungs. Microscopic examination of lung tissue shows interstitial pneumonitis and intraalveolar edema.

Image courtesy of Special Pathogens Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Disease, CDC.

**The full citation can be found in the lesson document and the associated teacher resources.

Case Map

You have put out an alert to other hospitals around the country. Doctors have been asked to review their records from the past two years and evaluate whether any of their patients have experienced unexplained respiratory illness resulting in death, with an autopsy examination demonstrating noncardiogenic pulmonary edema without an identifiable cause. Data begins to pour in and you categorize the information into a map that displays the number of suspected cases by state.

US Cases of the “Mystery Illness”

Of the reported cases, 65% are male. 75% of the reported cases are White, 15% are American Indian, 7% are Black, and 3% are Asian.

© 2011 Project Lead The Way, Inc.

Biomedical Innovation Project 5.1.1B Evidence Report #1 – Page 12