ُlaboratory interpretation 4th year

8/13/2019 Laboratory Interpretation 4th Year

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Laboratory interpretationKittisak Sawanyawisuth, M.D., M.A.S.

Department of Medicine,Faculty of Medicine, KKU


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Topics EKG

CXR

Miscellaneous


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Indication for EKG (Dx) Cardiac diseases

Chamber enlargement: LVH -> hypertension Myocardial ischemia Pericarditis, pericardial effusion

Pulmonary diseases Pulmonary embolism Cor pulmonale

Metabolic diseases Hyper/hypokalemia Hypocalcemia Digitalis intoxication


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Indication for EKG (Tx) Serial EKG for acute MI

Post treatment of arrhythmia


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Basic rules for EKG Grid 1 mm x 1 mm

Paper speed 25 mm/sec

1 mm = 1/25 = 0.04 sec = 40 msec

Sensitivity

0.5, 1, 2

Normal = 1


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EKG grid


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EKG complete leads Limb leads

I, II, III, aVR, aVL, aVF

Chest leads V1- V6


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EKG


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Normal findings in EKG P wave (atrial

depolarization) Biphasic in V1

PR interval 120-200 msec (3-5

mm)

QRS complex

< 3 mm (120 msec) QT interval Should < half of RR


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Normal in EKG aVR: all downward

Biphasic P wave in V1

Inverted T wave in V1 Q in III


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EKG interpretation Sinus rhythm?

Rate?

Axis? Chamber enlargement?

Ischemia

ST-T changes


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Rhythm


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Sinus rhythm P wave upward

PR interval 120-200 msec (3-5 mm)

Narrow QRS (< 120 msec, 3 mm)

Regular RR interval

Rate

60-90/min: Normal sinus rhythm < 60/min: sinus bradycardia

> 90/min: sinus tachycardia


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Which one is sinus rhythm?


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Rate


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Rate: in case of regular rhythm


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Sinus tachycardia Hyperthyroidism

Fever Effective volume depletion

Anxiety Pheochromocytoma

Sepsis Anemia

Hypotension and shock Pulmonary embolism

Acute coronary ischemia and myocardial infarction

Heart failure Chronic pulmonary disease Hypoxia Exposure to stimulants (nicotine, caffeine) or illicit drugs
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Sinus bradycardia Sick sinus syndrome

Exaggerated vagal activity

Increased intracranial pressure

Acute myocardial infarction(inferior wallMI)

Athletes

Obstructive sleep apnea

Drugs


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Axis


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Electrical

Axis

+

-

RAD

LAD


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Normal axis: I pos & aVF pos


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RAD: I neg & aVF pos


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LAD: I pos & aVF neg


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Causes of RAD Right ventricular hypertrophy Right bundle branch block

Left posterior fascicular block Normal variation (vertical heart with an axis of 90)

Mechanical shifts, such as inspiration andemphysema

Dextrocardia

Ventricular ectopic rhythms Preexcitation syndrome

Lateral wall myocardial infarction


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Causes of LAD Left ventricular hypertrophy Left bundle branch block Left anterior fascicular block Normal variation (physiologic, often with age)

Mechanical shifts, such as expiration, high diaphragm(pregnancy, ascites, abdominal tumor)

Congenital heart disease (atrial septal defect,endocardial cushion defect)

Emphysema Hyperkalemia

Ventricular ectopic rhythms

Preexcitation syndromes Inferior wall myocardial infarction.


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Chamber enlargement


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Atrial enlargement


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Chamber Enlargement

Right atrium enlargement

Peak of P wave > 3 mm

Left atrium enlargement

Width of P wave > 3 mm (Left Long)

Right ventricular hypertrophy

R/S wave ratio in lead V1> 1

Left ventricular hypertrophy S in lead V1or V2 + R wave in lead V5or V6> 35 mm

(Sense 1 only)

LV strain pattern: reverse check mark at V5-V6


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Atrial enlargement: RAH,LAH


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RVH


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LVH


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Biventricular enlargement


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Causes of chamber enlarged LAE: Mitral stenosis

RVH: ASD, Cor pulmonale, TR

LVH: hypertension, AS, AR, VSD


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Ischemic pattern


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Myocardial infarction(MI) Acute: ST elevation (Convex upward)

Old: Q wave (width 1 mm, > 2/3 of R) Note: Q wave is first negative wave

Q in only III: diaphragmatic Q wave (normal)

Ischemia: deep symmetrical inverted T wave

Q wave is more severe than inverted T wave

Wall

II, III, aVF: inferior wall V1-V3: anterior wall

I, aVL, V5, V6: lateral wall


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Acute anterior wall myocardial infarction


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Acute inferior wall MI


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Old anterior wall MI


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Old inferior wall MI


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ST-T change


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ST-T changes Hyperkalemia

Tall peak T wave

Hypokalemia

Flat T wave U wave

Hypocalcemia

Prolong QTc (corrected QT interval) QT (QT x 0.04)/sq. root of RR (RR x 0.04) Normal < 0.44 sec


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Prolonged QTc QT = 12 x 0.04

RR = 27 x 0.04

QTc = 0.48/1.08

= 0.48/1.04

= 0.46


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Pericardial effusion Generalized low voltage

< 5 mm in limb leads

< 10 mm in chest leads

Electrical alternans


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Electrical alternans


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Acute pericarditis


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Normal EKG


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Ectopic beats PAC (premature atrial

contraction)

Premature

Narrow QRS Not full compensatory

pause

PVC (prematureventricular contraction)

Premature

Wide QRS Full compensatory

pause


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What are they?


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Full compensatory pause: PVC


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Atrial fibrillation with rapid


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Atrial fibrillation with rapidventricular response

Narrow QRS

No P wave

Irregular RR interval


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Causes of AF HT

Mitral stenosis

Hyperthyroid

COPD

OSA


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Requirement Sinus tachycardia

Sinus bradycardia

Atrial fibrillation

Chamber enlargement

Acute myocardial infarction

PVC, PAC

Hyperkalemia, hypokalemia


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Chest film


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Chest X Ray (CXR): general

PA upright, AP supine

Exposure

Under exposure: too black

Good exposure: lung marking

Over exposure: too bright

Fully inspired?

Posterior ICS: 8-10

Position


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CXR (continue)

Soft tissue & Bone Trachea

Cardiac shadow

Aortic knob, pulmonary trunk,

left atrium,

left ventricle

Lungs Costophrenic angle

Free air below right diaphragm (Why right?)


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Normal CXR

PA or AP Exposure Fully inspired Position

Soft tissue & Bone Trachea Cardiac shadow

Aortic knob, pulmonarytrunk, left atrium, leftventricle

Lungs Costophrenic angle Free air


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Describe findings


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Mitral configuration

Enlarge left atrium

Prominent left atrium appendage

Double contour

Elevated left main bronchus

Increase pulmonary vasculature

Cephalization


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Left to right shunt (ASD, VSD, PDA)

Increase pulmonary trunk


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Varying degree of pulmonary congestion

L ft id d h t f il


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Left-sided heart failure

Increase cardio-thoracic ratio > 50%

Perihilar infiltration, cephalization


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P i di l ff i


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Pericardial effusion

Flask-shape cardiomegaly


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P i


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Pneumonia

Lobar infiltration with air bronchogram Streptococcus pneumoniae

Alveolar infiltration

Interstitial infiltration Viral pneumonia

Mycoplasma pneumoniae

Cavitary lesion Staphylococcus aureus Klebsiella pneumoniae


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TB


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TB

Active TB Cavitary

Miliary

Possible TB Nodular infiltration

Reticulonodular infiltration


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Miscellaneuos


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Miscellaneuos

Cavitary lesion with air fluid level Lung abscess

Cotton ball appearance

Hematogenous pneumonia Hematogenous metastasis

Honey comb appearance

Bronchiectasis Loss volume, trachea shift to same side

Atelectasis


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LFT

Indications


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Indications

Cirrhosis Jaundice

Hepatitis Acute viral hepatitis

Viral hepatitis: carrier

Drugs: anti TB (but ethambutol), simvastatin, NSAIDs,etc

Autoimmune

Normal values


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Normal values

Cholesterol 200 mg/dL

Albumin 4 gm/L

Globulin 3 gm/L

TB < 2 mg/dL

ALT 40 U/L

AST 40 U/L

Alkaline phosphatase 150 U/L

LFT interpretation


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LFT interpretation

Synthetic function: cirrhosis?

Excretory function: jaundice

Hepatocellular damage: hepatitis

Cholestasis: obstruction?

1 Synthetic function


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1. Synthetic function

Impaired -> cirrhosis Low cholesterol

Low albumin

Reverse Alb/Glob ratio

2 Excretory function: jaundice


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2. Excretory function: jaundice

Impaired excretory function if TB > 2mg/dL

If so, direct hyperbilirubinemia or indirect?

DB/TB < 15% -> indirect hyperbilirubinemia Prehepatic: hemolytic anemia

DB/TB > 15% -> direct hyperbilirubinemia

Hepatic: hepatitis -> elevated ALT, AST Post hepatic: cholestasis -> elevated ALP

3 Hepatitis


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3. Hepatitis

ALT > 100 U/L (3x of normal limits) AST > 100 U/L (3x)

ALT 120, AST = 230 Alcoholic hepatitis

ALT 1200, AST 1100 Acute viral hepatitis Ischemic hepatitis

Halothane

ALT 200, AST 180

Flare or active hepatitis (HBV, HCV)

Drugs

Autoimmune

alcohol

4 Cholestasis


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4. Cholestasis

If ALP > 3 x of upper limit

Medical cholestasis: drug induced

Surgical cholestasis: obstructive jaundice

Pale stool, itchy

Examples of LFT


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Examples of LFTChol 200 80* 220 210 250 330 350

Alb 4 2.5 4.2 3.8 3.9 1.8 3.5

Glo 3 3.2 3.2 3.6 3.1 3.5 3.4

TB


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Ascites

Cell count, cell differential

Ascites albumin

Ascites stainings and cultures

Depend on clinical course

G/S, culture: SBP

Cyto, wright: carcinomatosis peritonei

AFB: TB peritonitis

Ascites analysis


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Ascites analysis

WBC 340 cells/mm3, no RBC

PMN 10%, Lymph 90%

Albumin 3.5 gm/dL

DDx ??


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Ascites analysis


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Ascites analysis

WBC 123,450 cells/mm3, no RBC

PMN 70%, Lymph 30%

Albumin 3.5 gm/dL

G/S: pleomorphism

DDx ??


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Pleural fluid analysis

Pleural tapping


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Pleural tapping

Indications Diagnosis

Parapneumonic effusion

TB pleuritis Malignancy

autoimmune

Treatment

release



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Cell count, cell differential Protein, glucose, LDH

Stainings and cultures

Pleural gas


Cytology

Lymphocytic pleural effusion

Interpretation


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Interpretation

Exudative pleural effusion (1/3) Pleural protein/serum total protein > 0.5

Pleural LDH/serum LDH > 0.6

Pleural LDH > 200 U/L

Transudative pleural effusion

None of the above

Causes


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Causes

Exudative pleural effusion Parapneumonic pleural effusion

TB pleuritis

Malignancy CNT

Transudative pleural effusion Left-sided heart failure

Nephrotic syndrome


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Male, 78 y dyspnea 1 month

No orthopnea, no

PND Lateral decubitus?

Pleural tapping?

Pleural fluid for??

Pleural gas??



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WBC 1200 cells/mm3(PMN 25%, L 75%) Pleural protein 5 gm/L

Staining?

Pleural LDH?

DDx?


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Male, 78, COPD Fever, cough,

productive cough

(rusty sputum)

CXR: lobar right lung

Sputum G/S

Course


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Rx with ceftriaxone 1 g od Day 1: no fever

Day 5: fever

DDx??

PE


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Decrease breath sound right lung Decrease vocal resonance right lung

CXR: right pleural effusion Pleural tapping?

Pleural tapping with pleural gas


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pp g p g

WBC 12,000 cell/mm3 (PMN 90%, L 10%)

LDH 350U/L, protein 2.1 gm/L

Glucose 50 mg/dL

G/S: no organism

Pleural pH 7.10

Dx and Rx



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p

Complicated or early empyema Loculated

Pleural fluid pH < 7.20

Pleural fluid glucose < 60 mg/dL Positive Gram stain or culture

Empyema Gross pus

Treatment: ICD and ATB


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Female, 45 y DM type 2

Fever, left frank pain, dysuria 2 days

Dyspnea 1 day, no orthopnea, no PND PE: RR 24/m, Kussmaul breathing,

lungs: clear, heart: no murmur, CVA

tender left DDx causes of dyspnea

Lab


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Plasma glucose 340 mg/dL BUN/Cr 25/1 mg/dL

Na 140 mEq/L, K 5, HCO312, Cl 100

Interpretation?

Dx?

Wide anion gap metabolic acidosis


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g p

S: salicylic overdose A: alcoholic acidosis

L: lactic acidosis (sepsis)

U: uremic acidosis

D: DKA


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DM type 2 Plasma glucose 1080 mg/dL

BUN/Cr 30/1 mg/dL

Na 130, K 5, HCO325, Cl 100

Interpretation

Dx?

Hyperosmolar hyperglycemic state(HHS)


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(HHS) Serum osmolarity 2 Na + glucose/18

> 320 mOsm/kgH2O

No acidosis

ُlaboratory interpretation 4th year

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