Extreme Lab Values: Medical High and Low Findings In the Hospital.

Over my many years of hospitalist medicine, I've had the opportunity to witness extreme levels of human physiology.  I often go home at night wondering how God has made the human body so tolerable of such large variations in pathological conditions.  I shall use this post as an attempt to chronicle some of my more shocking variables I have laid eyes on.  I'm sure there are many I have forgotten, but for those I remember, please marvel in the endurance of the human body.  For some other experiences that deserve an entire post of their own, make sure to check out my other record hospital results over the years.

Highest Pulmonary Pressure:

This is my highest pulmonary pressure ever for a patient.  Known as Pulmonary Hypertension, they had a pulmonary pressure of  133 mm Hg on cardiac echo (estimated with a right ventricular pressure).  Holy Pulmonary Pressures Batman.


Crazy INR/Hgb Ratio:

A normal INR/Hgb ratio runs about 0.07. A normal PT/INR is 1.   It is the test we use for measuring "coumadin levels". For most conditions, doctors want an INR between 2 and 3 as stable coumadin or warfarin dosing.   A person not on coumadin and with normal body clotting activity has an INR of 1. A normal hemoglobin, or the oxygen carrying capacity of your red cells of your body, is about 13-15.

Therefore, a normal ratio of INR/Hgb is 1/14, or 0.07. So when I see a patient with a INR/Hgb ratio of 3.2 my hospitalist wheels started turning. A personal record for me.  And in an octogenarian none the less.

Anorexia Lowest Weight:

She was a 50 year old female and only weighed 24 kilograms. That's 53 pounds folks. That's my lowest weight ever for an anorexic patient.  My first plan of action was to get a clergy to come talk to her. I am way out of my league on this one. I have no idea how to help her. When she won't let me, as is usually the case in patients with anorexia.  They need fare more than just a hospitalists to care for them.


Highest HDL:  

What's the highest HDL ever?  For me it's this cirrhotic alcoholic who presented with an HDL of greater than 135.  This gentleman's HDL level is "desirable".  The way I see things, there's no need to worry about his end stage cirrhosis with all the life threatening sequela that comes with it.  With an HDL that high, his heart will live forever.  For most folks, the benefits of alcohol reach a dose dependent level rather quickly, usually at a maximum of one or two drinks a day.   For this guy, perhaps, I should tell him to keep drinking and drinking and drinking.    It may be the only thing keeping him alive. 

Highest pCO2:

197.

Facebook humor:

--> My highest pCO2 (that lived): 197!   Their chief complaint as the "Q sign"!



HIGHEST BLOOD SUGAR:

You may have just seen the highest blood sugar ever.  You are an internal medicine intern. It's your first month of residency. You're covering the VA medicine service tonight. You just finished your sixth admission of the night when in roles a 32 year old carny complaining of a three week history of progressive weakness. He is brought in by his beautiful wife at 2 am when she realize he can't get it up because he's too weak.

Here are your pertinent laboratories intern:
ABG 7.28/40/90
Na 132
K 2.5
Cl 100
T-CO2(bicarb) 17
Glu 1675
BUN 50
CR 2.8
  1. What's going on?
  2. What do you do about it?
  3. What are your main risks of treatment?
  4. What's your free water deficit and how should you replace it? (assume 70kg)
  5. What is your true sodium level?
  6. What's his delta anion gap?
Your supervisor went home with the swine flue and your attending missed his flight from Chicago after his wife caught him with another woman. It's just you intern. What are you going to do?

BLOOD ALCOHOL CONCENTRATION OF 0.708 AND NOT EVEN A NATIONAL RECORD


The highest blood alcohol concentration I've ever seen is around 0.550.  In my experience, it's usually a Native American that presents to the hospital with such an incredible level of intoxication.    The legal blood alcohol concentration in most states is 0.08.  That means blowing a blood alcohol concentration of 0.550 and 0.708 is about seven and nine times the legal limit respectively.  Most people would be dead on arrival with a blood alcohol concentration of 0.708.  But not this lady.  From the Smoking Gun:
Meet Marguerite Engle
That 0.708 is not even the national blood alcohol concentration record.  That record belongs to an Oregon woman, Terri Comer, 43, who blew a 0.720 last year after being discovered unconscious in her car.  Talk about extreme sports. It's clear to me that these blood alcohol concentrations indicate the body's remarkable ability to build tolerance in alcoholics.  And it's one reason alcoholics often believe they don't have a problem, when clearly, they do.

MOST ER VISITS.

 I don't know what the record number of hospital visits are out there are. But I saw a guy in the ED the other day that had 240 ER visits in the last six years. That's 40 visits a year, every year for six years. That's an average of one visit every 9 days for six years. That's six long and painful years. That doesn't even include all the numerous admissions to the hospital. Imagine spending over 10% of your life in the emergency room for six long years.


FASTEST PATIENT EXAM

This patient represents my fastest patient exam ever.  She'd been hospitalized for over two months awaiting placement in a nursing home. Nobody wanted her because she represented too great a risk to other nursing home patients.  It's interesting that a hospital with an emergency department can be forced to see every patient that comes through their doors, but every nursing home in this universe can refuse to accept any patient at any time.

This is an example of one of those patients that can take days, weeks, sometimes months to place.  They aren't safe to go home because they lack even the capacity to make poor medical decisions.  Their family abandons them with the mentality that it isn't their problem to fix.  The nursing homes don't care.  They have every right to pick and choose, just like doctors do as an outpatient.  No insurance?  That's a problem.   Bad insurance?  Bad disease?  Sorry, that's the hospital's problem.

A while back a patient was sued by a hospital because they refused to go to the only nursing home that would accept them.  The patient instead wished to stay in the hospital, I suspect forever.    Fortunately, the hospital isn't an appropriate place for long term management of stable disease. 

In this case, every morning this patient would pull her sheets over her head and sleep in peaceful seclusion.  Every morning she'd have nothing to say.  Every morning I would wake her up and interrupt her peaceful dreams.  Why?  Every morning I am required to write a note on her because hospital bylaws require a daily evaluation by  the attending physician. That' me, the hospitalist.  So every day I am required to do an evaluation, the depth of which is determined by me.  I can choose how much or how little I wish to do.  I let the circumstances guide my decision making process. 

After two months in the hospital, it becomes painfully  silly for me to wake her up every morning, pull the sheets off her head and ask her if she slept well last night.  So this time I didn't.  I asked the nurse if the patient had any issues or concerns.  I looked at the patient sleeping under her blanket from the bedside and I wrote my low level 99231 hospital follow up note
126/78  *  72  *  20  *  98.6
 Dementia, awaiting placement
That's my evaluation and it meets every lawful requirement necessary to be paid for by the Medicare National Bank for a CPT® 99231 evaluation.

OLDEST ALCOHOLIC

So I think I happened across the oldest case of alcoholic hepatitis ever.  He was 99 years old and loved his vodka.  He even admitted to a "little vodka every night".  He came in with a classic 2:1 AST:ALT ratio on his liver enzymes in a non obstructive pattern.   But it didn't click with me at the time.  He's  99 years old.  What kind of 99 year old gets alcoholic hepatitis?  It's unheard of.

In the course of his ER evaluation, he was found to have a markedly dilated common bile duct of 25 mm, despite his previous cholecystectomy.  With a little conservative management By doing nothing but observing him for a few days all his liver enzymes returned to normal.  That's how you diagnose alcoholic hepatitis in a 99 year old.   Patients lie to their doctor,  even the 99 year olds.  So what.  You're my hero old man.   Don't let anyone tell you differently.  Just make sure the social worker sends you to a vodka friendly nursing home where you might even meet my patient who was drunk at the nursing home with an alcohol level of 0.210.  That's the drunkest nursing home patient I've ever met! You guys can be roommates.

HIGHEST WHITE COUNT (LEUKOCYTOSIS)

I saw a patient once with a a white counter of 450K.  That's four-hundred and fifty thousand!.  The patient had chronic lymphocytic leukemia (CLL).  I found out the hemoglobin and platelet count couldn't' even be reported because of interference from the leukocytes.  

LOWEST HEMOGLOBIN

3.2.  He'd never seen a doctor and made it to 76 years old.  UPDATE:  2.4.  Now that's low!

WORST SOCIAL HISTORY

This has to be the worst social history ever.  Everyone knows that in order to get paid under the evaluation and management (E/M) rules of the Medicare National Bank, the more nonsense information you obtain, the more you get paid.  Does it meet Medicare medical necessity?  Of course it does.  It always does.  For your documentation to support CPT®  99223  instead of  99221, the social history component is mandatory. 

So what do physicians do for their documentation?  They write something, anything, just to meet the compononent requirements for E/M, even if you think it has no bearing on the care plan going forward.  There is nothing anywhere that clarifies when a social history is not indicated.  It will always be indicated.  And to get paid, physicians must  include it.  That's why doctors document it.  I would much rather just move on to more important things when social history doesn't matter.  But the Medicare National Bank makes it matter, every time.  That's the way E/M works.  So what did the worst social history ever look like?   Here is an APRN social history I saw once!
Patient presents with her daughter.
I don't know what they're teaching in nursing school these days or if taking a social history is even  a nursing education requirement.  It's obviously not an APRN requirement, at least not for this one.    That's not even a history.  That's an observation.  It describes the present.  If you want to make it appear like you at least applied some effort, say that the patient was drinking or smoking with her daughter.  Now that's a social history worth documenting.  What's the worst thing you've ever seen documented for social history?

HIGHEST AMMONIA LEVEL

Ammonia is a byproduct of metabolism that builds up in patients with advanced liver disease.  The treatment includes frequent stooling with the help of lactulose therapy.  Often, patients with advanced liver disease are hepatocellular unable to comply with recommended therapies.  While I was trained not to follow absolute ammonia levels for determining treatment plans, knowing trends can be helpful.  Normal ammonia levels are in the teens or less.  Some patients with chronic liver disease can live with ammonia levels in the 100 range.  This is normal for them.  What's the highest level I've ever seen?  234.  They presented with somnolence.  As expected.

UPDATE:  The highest ammonia level I have now experienced is 388.  They were completely unresponsive.  

LOWEST ABSOLUTE NEUTROPHIL COUNT (ANC)

Absolute neutrophile counts are calculated by taking the total white blood cell count and multiplying that by the percent of neutrophils on a complete blood count (CBC).  Often, an ANC while be provided in the CBC printout showing the absolute value of neutrophils.  Low ANC values are often the result of chemotheropy induced cytotoxicity.  Low ANC values increase the risk of infections and the body is unable to mount an immune response.  An ANC of less than 500-1000 begins to significantly increase the risk of infections.  Neutropenic fever often requires hospitalization  and a source of infection  for the fever.  What's the lowest ANC I've ever seen?  Seven.   That's 7.  Not 70 or 700  That's pretty low.  It was due to a complication of clozaril therapy, used in the treatment of schizophrenia related disorders.

HIGHEST TSH

291.  Presentation consistent with myxedema coma (bradycardia, total body swelling, rhabdo, mental status changes, hoarse voice, constipation). 

READER SUBMITTED EXTREME CLINICAL FINDINGS FROM FACEBOOK
  • Glucose of 12mg/dL and still coherent enough to notify staff she was a DNR.
  • Troponin of 9.8 admitted to the med/surg floor.
  • Dig level 6.5. It was being checked every day, but no one was reading the lab results apparently. Nurses (LVNs) kept administering the Dig every day until she was my patient and I notified the doctor. "Wonderful" for-profit hospital I briefly worked at my first year as a nurse.
  • INR>22---->FFP and 10mg vitamin K---->INR 4---->INR 18. We played that game for 2 weeks before he admitted taking rat poison on a dare.  Had to be on vitamin K 100mg daily.
  • Troponin of 98.... A 90+yr old female with inferior wall MI. Sent to ER for "failure to thrive".
  • Sodium so high because the mom put it in the tiny babies formula...CPS.
  • I was working with a charge nurse once, she seemed a little off. Did her BS...14mg/dl. A piece of cheese and some peanut butter, and we were back in business at 60. That's how we rolled on night shift!
  • Had a patient with a .45 BAC, that wasn't all that interesting until I mention they were ALREADY in active DTs.
  • One patient with 200+ ER visits in less than 2 years! (And thats just OUR ER! Who knows with all hospitals combined.) Along with the county record for record ambulence rides.
  • I had a patient once who weighed 1200+ lbs. We had two beds strapped together and had to bring the person up in a cargo elevator.
  • Male patient with a BNP > 4900. Female patient with a blood sugar <10. Multiple patients with CK's >20,000, usually prolonged down time from recreational drug use.
  • We have a patient who has had so many vascular surgeries (barely any veins in her arms) that her sbp reads 60 in her b/l arms. 80s in her legs. So we just check to see if she has her pulses and she's good to go!
  • Ammonia level of 779!
  • Had a WBC of 49.5. I called the hospitalist laughing to report it. What was even better was the nurse giving me report from another facility didn't mention he was tubed till I asked. Then she said, "Oh yeah, I forgot he also coded too."
  • Potassium of 1.1. Patient didn't like to take his potassium pills because they were too "big" to swallow. So he kept taking his Furosemide and no potassium supplements. I also had a massive GI bleeder with a hemoglobin of 2.2. I think by the time this patient left the hospital he needed 15 units of PRBCs.
  • Hgb of 4.6...been really tired....drove to the doctor office and then to the hospital!
  • A blood sugar of 8, brain damage occurred. They were semi comatose afterward. As far as I know they became a trach/peg blue light special...sad...there was no explanation for it. The ER chem panel had shown a BS that was normal the night prior and they had no history of DM. They were young as well, in their 40's. The intensivist did some test for extrinsic insulin but that turned up negative.
  • RBC of 1.8, before hydration. He was the whitest black man I have ever seen.
  • WBC over 1 million. The Coulter counter went "TILT" as all the lights flashed on. We had several patients when I worked in hematology lab before nursing that had more WBCs than rbc's, and bizarre blast cells. We asked one hematologist who came down to see the slide what the patient looked like, he said that "She can't wear a turtleneck." Massive lymphadenopathy. I think the lowest HCT was under 12 with an unreadable HGB (kid with ALL).
  • I had a patient with an troponin of 23. Still hanging out like it was no big thing, up and moving. I thought the labs were wrong until it only trended down to 22 and 20.
  • Wow! Never seen a K that low! Mine was a lactic acid 26 - was septic and had a seizure!
  • Last week patient admitted on the medical floor without cardiac monitoring with a K+ of 1.2.
  • I had a patient with an INR=18.1
  • My uncle went to ED in Feb and his WBC was 452k. I was SURE my Aunt was mistaken and heard it wrong. Sure enough. He was dx with AML. He's in a clinical trial at MD Anderson now!
  • I've had a patient with a critical WBC of "to many to count" for the 4th day in a row.  Over 450K.
  • We had to send in one of my patients with an INR of 19.2. Nobody could figure out how he went from 2.2 the week before to 19.2, unless someone fed him a crap load of coumadin!
  • We had a patient that was over 900 pounds. It took 8 of us to do anything with her. Her trach was so tenuous, only the doctors were allowed to clean and change the inner cannula. Glucose of 1300 (Patient admitted with DKA), Glucose of 18 (my personal best and still consicious!), Lipase over 1000.


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4 Outbursts:

  1. "Somebody want to get me a nitro patch?"

    ReplyDelete
  2. What was their systolic blood pressure?

    ReplyDelete
  3. a) how good was the window and view of the TR jet?
    (and how good is your echo tech...?)
    b) what was the correlation with the SG cath measurements?

    Highest real PA pressure that I've seen is 110 in a 35 yo M with idiopathic PAH. He's in some NIH trial now.

    CardioNP

    ReplyDelete
  4. Dang! And here I thought 89 was the worst I had ever transcribed (by a cardiologist)!!

    ReplyDelete

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