Question

The patient described in this case has multiple-organ involvement; therefore, the clinician requested a significant number of diagnostic tests, including clinical laboratory tests, to rule in and rule out various diseases and disorders.

Wanda, a 65-year-old woman who is a chronic alcoholic suddenly collapsed at home and was transported to the emergency department (ED). Her medical history includes hypothyroidism, chronic renal impairment, and osteopenia. The patient complained of mild epigastric pain, with occasional pain radiating to the right costal margin. She denied chest pain, headache, or vertigo. She had shortness of breath (dyspnea) on examination. Her medications consisted of furosemide (a diuretic), potassium, captopril (ACE inhibitor), and thyroxine. She has smoked for about 30 years.

Physical examination revealed a tired and lethargic-looking woman. Her weight was 130 pounds and her height was 61 inches. Her blood pressure was 110/70 lying down and 90/60 sitting down, with a pulse rate of 102 beats per minute. Other significant findings were crepitus (crackling or popping sound) in her chest, marked cardiomegaly, and pulmonary edema.

Issues and Questions to Consider

1. Identify several clinical observations relevant to Wanda’s history and physical examination.

2. List examples of diagnostic laboratory and nonlaboratory (e.g., X-ray) tests that may provide the clinician with useful data to support clinical findings.

The results of clinical laboratory tests and additional diagnostic tests are as follows:

Blood Chemistries	Results	Reference Interval (RI)
Sodium (mEq/L)	144	136–145
Potassium (mEq/L)	4.4	3.5–5.1
Chloride (mEq/L)	101	98–107
Bicarbonate (mEq/L)	7	23–29
Anion gap (mEq/L)	36	6–10
Glucose (mg/dL)	100	74–100
Creatinine (mg/dL)	2.5	0.9–1.3
Urea nitrogen (mg/dL)	11.2	6–20
Lactic acid (mg/dL)	88.3	5–12
Calcium (mg/dL)	8.9	8.7–10.0
Phosphate (mg/dL)	3.1	2.5–4.5
Magnesium, mg/dL	1.2	1.5–2.3
Albumin (g/dL)	3.1	4.0
Gamma glutamytransferase (U/L)	389	1–25
Ethanol	Not detected	Undetectable
Alkanine phosphase (U/L)	250	40–115
Alanine amino transferase (U/L)	1880	0–55
Asparate amino transferase (U/L)	7542	5–34
Lipase (U/L)	125	13–60
Troponin I (ng/mL)	0.48	0.04
B-type natriuretic peptide (pg/mL)	458	≤106
pH	7.10	7.35–7.45
Thiamine (nmol/L)	2.7	70–180
Erythrocyte transketolase (U/L)	34	150–200
Other nonclinical laboratory tests:
Left ventricular ejection		Normal
Fraction (%)	32	>50

Issues and Questions to Consider

1. Based on all of the information provided, including laboratory tests, identify possible medical disorders affecting this Wanda.

2. What is the relationship between the increased serum BNP and the decreased thiamine levels?

3. What type of assay is erythrocyte transketolase?

4. Explain why erythrocyte transketolase is decreased.

Answer 1

Answer:

☆ * Shortness of breath

* Blood pressure ( sitting) 90/60

* Pulse rate 102 bpm

* On auscultation crepetus

* Pulmonary edema

* Cardiomegaly

* Elevated blood values

☆* Physical examination

* Blood investigations

* ABG analysis

* Chest xray

* Echocardiography

* ECG

☆ * Metabolic acidosis - low bicarbonate levels

* Congestive heart failure - elevated troponin I, lactic acid

* Liver cirrhosis

* Liver or bile duct damage

* Beriberi - low thiamine levels

* Renal failure - elevated creatinine and BUN

☆ Thiamine concentration in the blood has negative correlation with plasma BNP concentration

☆ Erythrocyte transketolase in blood is an active assay used to detect thiamine deficiency

☆Erythrocyte transketolase is decreased due to thiamine deficiency