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OSCEw ebinarseies:Blood testinvestigations Amirreza SaadatniadIntroduction Bloods are an integral aspect of data interpretations clinical settings Although you are often given isolated values - It is important to monitor trends You should be given normal values in exams, but it does help to have an idea for what is right and wrong Units and ranges can vary Have a systematic approachFull blood countFull Blood Count The full blood count gives insight into the cellular components of blood including white blood cells, red blood cells, and platelets providing numerical values relating to these cells (e.g. amount of them, size, contents) These results provide vital clues to the presence of underlying pathology. A standard FBC can be broken down into the following red cell, white cell and platelet testsRed blood cells •Haemoglobin (Hb): amount of haemoglobin (oxygen-carrying protein) in whole blood •Haematocrit (Hct): percentage of the blood sample that is made up of red cells •Mean corpuscular volume (MCV): the average size of the red cells present in the blood sample •Red cell distribution width (RDW): a range from the largest red cell present to the smallest red cell present •Red cell count (RCC): the number of red cells present per unit volume of blood •Reticulocyte count: the number of reticulocytes (immature red cells) •Mean corpuscular haemoglobin (MCH): the amount of haemoglobin per red blood cell •Mean corpuscular haemoglobin concentrate (MCHC): average concentration of haemoglobin in a given volume of bloodaRed cell tests Red cell tests can quantify the amount of haemoglobin/red cells present in a sample: •An abnormally high number of haemoglobin/red cells is known as polycythaemia. Red cell tests can also provide important insights into the underlying cause(s) of anaemia or polycythaemia by looking at the average size of the cells and how much haemoglobin is contained within them.Case Presentation A 21 year old female presents to her GP with tiredness and palpiations Hb 99 115-165 RBC 4.3 3.8-5.8 HCT 0.38 0.37-0.47 MCV 61 76-96 MCH 29 27-32 MCHC 328 201-350 RDW 12 10-14 Platlets 267 150-400Case Presentation A 21 year old female presents to her GP with tiredness and palpitations Hb 99 115-165 Microcytic Anaemia RBC 4.3 3.8-5.8 microcytic anaemia HCT 0.38 0.37-0.47 TAILS: Thalassemia/haemoglobi MCV 61 76-96 nopathies, Anaemia of chronic disease/inflammation, Iron MCH 29 27-32 deficiency anaemia, Lead MCHC 328 201-350 poisoning, Sideroblastic RDW 12 10-14 anaemia Platlets 267 150-400Anemia Not the complete diagnosis What other investigations to consider?Anemia Not the complete diagnosis What other investigations to consider? Blood films Hematinic Electrophoresis Coeliac serology Bone marrow aspirate Ultrasound/other imaging EndoscopyCase Presentation A 21 year old female presents to her GP with tiredness and palpitations Hb 99 115-165 Iron Deficiency Anaemia RBC 4.3 3.8-5.8 • Investigation findings in iron HCT 0.38 0.37-0.47 deficiency anaemia include: • Low MCV <80 MCV 61 76-96 MCH 29 27-32 • Serum iron: low • Transferrin saturation: low MCHC 328 201-350 • Ferritin: low RDW 12 10-14 • Total iron-binding capacity: high Platlets 267 150-400Anemia •Microcytic anaemias have an MCV of less than 80 and include iron deficiency anaemia, sideroblastic anaemia and thalassaemia. •Normocytic anaemias have an MCV of between 80-100 and include anaemia of chronic disease, hereditary spherocytosis, sickle cell anaemia, paroxysmal nocturnal haemoglobinuria, G6PD deficiency, immune haemolytic anaemia, microangiopathic haemolytic anaemia and underproduction of RBCs. •Macrocytic anaemias have an MCV of greater than 100 and include folate deficiency (megaloblastic), vitamin B12 deficiency (megaloblastic anaemia) and non-megaloblastic anaemia.Case Presentation 19 year old man presents to ED with upper abdominal pain. O/E: splenomegaly Hb 108 130-180 RBC 4.1 4.6-6.5 HCT 0.3 0.40-0.54 MCV 76 76-96 MCH 25 27-36 MCHC 367 301-350 RDW 19 10-14 Platlets 129 150-400Case Presentation 19 year old man presents to ED with upper abdominal pain. O/E: splenomegaly Sickle cell anemia Hb 108 130-180 RBC 4.1 4.6-6.5 HCT 0.3 0.40-0.54 MCV 76 76-96 MCH 25 27-36 MCHC 367 301-350 RDW 19 10-14 Platlets 129 150-400Case Presentation 19 year old man presents to ED with upper abdominal pain. O/E: splenomegaly Sickle cell anemia Hb 108 130-180 RBC 4.1 4.6-6.5 HCT 0.3 0.40-0.54 MCV 76 76-96 MCH 25 27-36 MCHC 367 301-350 RDW 19 10-14 MCHC – raised in sickle cell anemia Platlets 129 150-400 and hereditary spherocytosisCase Presentation 19 year old man presents to ED with upper abdominal pain. O/E: splenomegaly Thalassemia much lower MCV and RDW would be normalWhite blood cells and platlets •White blood cell count (WCC): the number of white blood cells cellse blood cell differential: the breakdown of the white blood cell count into different •Platelet count: the number of platelets •Mean platelet volume (MPV): the average size of platelets •Platelet distribution width (PDW): measures variability in platelet sizeWhite cell summary Leukopenia – marrow disorders, drugs (cytotoxic), infection Leukocytosis – infection, inflammation, malignancy Important to consider differentials – what specific cells Neutrophils - bacterial infection, trauma, inflammation Lymphocytes – viral infections Eosinophils – atopy, parasitic infectionsn (e.g TB), autoimmunity Basophils – viral infections, urticaria White cell cases WBC 16.7 4-11 Neut 12.5 2-7.5 Lymph 3.8 1-4 Mono 0.3 0.2-1 Eosin 0.1 0.0-0.4 Baso 0.0 0.0-0.1 White cell cases WBC 16.7 4-11 Neut 12.5 2-7.5 Lymph 3.8 1-4 Mono 0.3 0.2-1 Eosin 0.1 0.0-0.4 Baso 0.0 0.0-0.1 Bacterial infection White cell cases WBC 13.5 4-11 Neut 6.6 2-7.5 Lymph 7.1 1-4 Mono 0.35 0.2-1 Eosin 0.2 0.0-0.4 Baso 0.1 0.0-0.1 White cell cases WBC 13.5 4-11 Neut 6.6 2-7.5 Lymph 7.1 1-4 Mono 0.35 0.2-1 Eosin 0.2 0.0-0.4 Baso 0.1 0.0-0.1 Viral infection White cell cases WBC 131 4-11 Neut 3.8 2-7.5 Lymph 120 1-4 Mono 0.2 0.2-1 Eosin 0.0 0.0-0.4 Baso 0.0 0.0-0.1 White cell cases WBC 0.7 4-11 Neut 0.5 2-7.5 Lymph 0.2 1-4 Mono 0.0 0.2-1 Eosin 0.0 0.0-0.4 Baso 0.0 0.0-0.1 White cell cases WBC 0.7 4-11 Neut 0.5 2-7.5 Lymph 0.2 1-4 Mono 0.0 0.2-1 Eosin 0.0 0.0-0.4 Baso 0.0 0.0-0.1 Aplastic anemia Cytotoxic – patient after chemotherapyPlatelets summary Thrombocytopenia Increased destruction (e.g autoimmune, DIC, splenomegaly) Thrombocytosis Essential Reactive (infection, inflammation, trauma)Liver function testsBasic LFT panel • Basic LFT panel •Alanine aminotransferase (ALT) •Aspartate aminotransferase (AST) •Alkaline phosphatase (ALP) •Gamma glutamyl transferase (GGT) •Albumin •Bilirubin •Conjugated by UGT enzyme •Prothrombin time (PT) or INR •Clotting factors II, VII, XI, X, protein C and SLiver enzymes Liver enzyme Location Raised? ALT Liver (hepatocytes) Hepatocellular injury AST Liver (hepatocytes) Liver damage Striated muscles (skeletal and Skeletal muscle damage cardiac muscle) (rhabdomyolysis) Erythrocytes Cardiac muscle damage (IM) Haemolysis ALP Biliary system Cholestasis Bone Increased bone turnover Placenta Pregnancy GGT Biliary system epithelial cells Cholestasis Alcohol Drugs e.g. phenytoinLFT patterns • ↑↑ALT and AST and conj. Bilirubin ± ↑ALP ⇒ hepatocellular injury • Viral hepatitis, autoimmune, drug induced e.g. paracetamol overdose, alcohol induced (AST/ALT >2, ↑↑GGT) • ↑↑ALP + normal GGT (isolated ALP rise), likely to have non-hepatic causes • Paget’s disease, bony metastases, renal osteodystrophy • ↑↑ALP + ↑GGT ⇒ highly suggestive of cholestasis • Isolated rise in bilirubin • Pre-hepatic causes e.g. haemolytic anaemia • Impaired conjugation e.g. Gilbert’s syndrome • Impaired hepatic uptake e.g. CHF , drugsLFT case scenarios • A 24-year-old male is found to have the following liver function tests as part of a routine health check: Bilirubin 37 µmol/L (0-18), AST 14 IU/L (5-40), ALT 26 IU/L (5-45), alkaline phosphatase 125 IU/L (30-130), Albumin 40 g/L (36-45), Hb 13.7 g/dL (11.5-15.5), reticulocyte count 1.2%. What is the most likely diagnosis?LFT case scenarios • A 24-year-old male is found to have the following liver function tests as part of a routine health check: Bilirubin 37 µmol/L (0-18), AST 14 IU/L (5-40), ALT 26 IU/L (5-45), alkaline phosphatase 125 IU/L (30-130), Albumin 40 g/L (36-45), Hb 13.7 g/dL (11.5-15.5), reticulocyte count 1.2%. What is the most likely diagnosis? Gilbert’s syndromeLFT case scenarios • A 42-year-old female patient presents with jaundice, fatigue and abdominal pain. Her blood test shows: ↓ albumin, ↑ Conj. Bilirubin, AST, ALT, GGT, INR AST/ALT > 2LFT case scenarios • A 42-year-old female patient presents with jaundice, fatigue and abdominal pain. Her blood test shows: ↓ albumin, ↑ Conj. Bilirubin, AST, ALT, GGT, INR AST/ALT > 2 Hepatocellular injury, likely alcohol induced Further differentials to rule out - Viral hepatitis - Drug induced e.g. minocycline, azathioprine - Autoimmune e.g. ANA, ASMALFT case scenarios • A 67 y/o female presents with RUQ pain, fever, jaundice. She is slightly confused. Her LFT results show: ↑ Bilirubin, GGT AST, ALT, and albumin are normalLFT case scenarios • A 67 y/o female presents with RUQ pain, fever, jaundice. She is slightly confused. Her LFT results show: ↑ Bilirubin, GGT AST, ALT, and albumin are normal Cholestasis (post-hepatic jaundice) Likely ascending cholangitisUrea and Electrolytes Summary Na Hyponatremia - Hypernatremia in dehydration, diabetes insipidus, hyperaldosteronism K Hypokalemia: diuretics, D+V, hyperaldosteronism, alkalosis Hyperkalemia: renal failure, Addison's, rhabdomyolysis, acidosis, k-sparing diuretics Urea A waste product of protein metabolism Excreted by the kidney so gives an idea of kidney health Raised in catabolic states and upper GI bleeding Creatinine Produced by the muscles therefore varies according to muscle mass Excreted by the kidney so gives an idea of kidney health eGFR Can be calculated with 24 hour creatinine clearanceUrea and Electrolytes cases A 87-year-old female is admitted to hospital with confusion Na 152 135-145 K 5.2 3.5-5.5 Urea 28 2.5-6.7 Creat 152 70-150 Urea and Electrolytes cases A 87 year old female is admitted to hospital with confusion Na 152 135-145 K 5.2 3.5-5.5 Urea 28 2.5-6.7 Creat 152 70-150 Dehydration very high urea, marginally raised creatinine = pre- renal cause high urea, high creatinine = intra/post renal causesUrea and Electrolytes cases A 50 year old female presents to ED with vomiting and diarrhea for 3/7 Na 130 135-145 K 3.2 3.5-5.5 Urea 23 2.5-6.7 Creat 173 70-150 Urea and Electrolytes cases A 50 year old female presents to ED with vomiting and diarrhea for 3/7 Na 130 135-145 K 3.2 3.5-5.5 Urea 23 2.5-6.7 Creat 173 70-150FOR FEEDBACK ANDQUERIES: Email@ info@bidasw.com