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Project 5.1.1B Evidence Report #1General Lab TestsBlood work

Lab: Auto DifferentialTest 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 CountTest 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

150,000 - 400,000 platelets/mc

100,000 60,100 120,000 140,000 89,000

© 2011 Project Lead The Way, Inc.Biomedical Innovation Project 5.1.1B Evidence Report #1 –

blood. L

Lab: Comprehensive Metabolic PanelTest 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: LipidTest 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 -

103 90 100 125 89


159 mg/dL

High: 160 - 189 mg/dL

Very High: 190 mg/dL and higher

Lab: Additional Blood TestsTest 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

UrinalysisMacroscopic 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 ResultsPatient Vital Signs

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

Patient 1 Patient 2 Patient 3Date 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 5Date 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 NotesDue to high WBC counts, all patients were administered broad-spectrum antibiotics.

Patient 1By 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 2On 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 3The 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 4Patient 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 StudiesBecause of declining heart rate and apparent hypotension, a cardiac workup was ordered for all five patients. EKG and echocardiogram results are found below.

EKGThe 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

EchocardiogramIn 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.

EMGEach 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.


http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cardio&part=A39&rendertype=figure&id=A119

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cardio&part=A39&rendertype=figure&id=A119

Imaging ResultsBecause 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 admissionHeart size appears normal. Scan shows minimal changes of interstitial pulmonary edema.


Repeat scan – 3 days post admissionHeart size appears normal. Scan shows interstitial edema progressing to alveolar edema. Progression is rapid. Pleural effusions are visible.

Pathology ReportA 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 MapYou 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.


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.


US Cases of the “Mystery Illness”

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