Thanks to David G Williams for suggesting this Case.
A 52 year old man, visiting the Haematology Outpatient Department. No
clinical information is given on the request card. Serum results are
Sodium: 169 mmol/L (134 - 145)
Potassium: 3.3 mmol/L (3.5 - 5.2)
Urea: 2.8 mmol/L (2.8 - 7.0)
Creatinine: 81 umol/L (62 - 133)
Adjusted Calcium: 1.79 mmol/L (2.10 - 2.55)
Alkaline phosphatase: 229 IU/L (<126)
Albumin: 26 g/L (35 - 49)
Bilirubin: 13 umol/L (3 - 22)
Gamma GT: 141 IU/L (<35)
ALT: 46 IU/L (<25)
Glucose: 40.6 mmol/L (fasting, 3.5 - 5.8)
This horrid set of abnormalities provoked 39 replies - I particularly liked
'what a stinker' - thank you, Philip. It also provoked some disagreement
between the assessors.
4 said that these results were unlikely from a Haematology outpatient;
[0.8*]
5 would repeat the analyses before further action; [0.3]
3 would check the type of sample tube before further action; [1.3]
18 mentioned the need for urgent contact with the Clinicians [1.5]
21 queried some type of sample contamination; [1.3]
6 queried whether this was a known diabetic; [0.3]
3 suggested HONK (hyperosmolar nonketotic coma); [0.5]
3 queried Cushing's disease or on steroids; [-0.8]
2 stated severe dehydration was present; [-1.0]
2 queried hyperaldosteronism; [-0.8]
2 mentioned the raised enzymes and queried alcoholism; [0.8]
1 queried neoplasm. [-0.8]
13 advised an urgent repeat sample; [1.5]
4 would measure bicarbonate; [-0.3]
2 would suggest measuring serum total protein; [0.8]
2 would suggest measuring urine osmolality; [0.0]
1 each would measure
magnesium; [0.5]
phosphate; [0.3]
Vitamin D; [-0.5]
blood alcohol; [-0.3]
serum protein electrophoresis [-0.3]
adjusted calcium after rehydration. [0.5]
1 suggested urgent hospital admission. [0.0]
The Consultant Haematologist was very puzzled by these results, as the
patient had seemed well in Outpatients. It eventually transpired that the
sample had been taken from a blood transfusion bag, and was contaminated by
CPD preservative (sodium citrate, phosphates, and dextrose).
Several people have suggested that I should repeat an earlier Case for
Comment to see if there has been any change in the pattern of comments over
the two years that these Cases have been running. I was delighted with this
Case, since it was almost identical to Case 10 (Christmas 1997). With Case
10, 40% of participants suggested an urgent repeat sample (here suggested
by 33%); but only 8% of participants correctly guessed the type of
contamination (here correctly guessed by 13%). I guess that this is no
significant difference!
Best wishes
Gordon Challand
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
|