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Lab Investigation Analysis - Mr. Rajveer Rai, 28M

D Y Patil Hospital, Navi Mumbai | UMR: 4251938 Context: Widal test ordered - likely enteric fever workup

COMPLETE BLOOD COUNT (CBC)

Parameter	Patient Value	Normal Range	Status
Hb	14.7 g/dL	13-18 g/dL	✅ Normal
HCT/PCV	42.2%	40-54%	✅ Normal
WBC	7.39 x 10³/UL	4-11 x 10³/UL	✅ Normal
Neutrophils	81.6%	40-70%	⚠️ HIGH - Neutrophilia
Lymphocytes	10.7%	15-40%	⬇️ LOW - Relative lymphopenia
Eosinophils	0.1%	0-7%	✅ Normal
Basophils	0.2%	0-2%	✅ Normal
Band Cells	861/30 (likely 861 x 10³)	-	⚠️ Elevated bands - left shift
Platelets	272 x 10³/UL	150-450 x 10³/UL	✅ Normal

CBC Interpretation:

Neutrophilia (81.6%) with relative lymphopenia (10.7%) is a classic pattern in enteric fever (typhoid). Despite total WBC being normal, the differential shift is significant.
In typhoid fever, the total WBC is often normal or low-normal, but the neutrophil predominance and band cells suggest ongoing bacterial infection.
Left shift (band cells) indicates an active bacterial process driving immature neutrophil release from bone marrow.
Haemoglobin and PCV are normal, ruling out significant anaemia.

COAGULATION PROFILE

Parameter	Patient Value	Normal Range	Status
PT/INR	1.57	< 1.2 (INR)	⚠️ MILDLY ELEVATED
PTT	(normal range 30s)	25-35 sec	✅ Appears within range

Interpretation:

INR of 1.57 represents mild prolongation of the extrinsic coagulation pathway (factors I, II, V, VII, X).
In the context of typhoid or liver involvement, this may indicate early hepatic dysfunction affecting vitamin K-dependent factor synthesis.
As per Miller's Anesthesia: "prolonged PT/INR is not specific for liver disease - it may also represent vitamin K deficiency, warfarin effect, or a genetic factor deficiency." However, in this clinical context with abnormal LFTs, early hepatic involvement is the most likely cause.
Fibrinogen, D-Dimer, ACT are not filled in - these would help rule out DIC.

ELECTROLYTES (OLYTES)

Parameter	Patient Value	Normal Range	Status
Na⁺	136 mEq/L	135-148 mEq/L	✅ Low-normal
K⁺	3.73 mEq/L	3.5-5.3 mEq/L	✅ Normal
Cl⁻	103 mEq/L	98-108 mEq/L	✅ Normal
Ca, Mg, Bicarb, Inorg Phos	Not recorded	-	-

Interpretation:

Sodium at 136 is low-normal. In typhoid, mild hyponatremia (Na < 135) is a known complication due to SIADH and GI losses. This patient is borderline - important to trend.
Potassium and chloride are normal.
Anion gap calculation is not possible without bicarbonate, but chloride and sodium suggest no gross acid-base disturbance.

RENAL FUNCTION TESTS

Parameter	Patient Value	Normal Range	Status
BUN	8.88 mg/dL	7-20 mg/dL	✅ Normal
Creatinine	0.92 mg/dL	0.5-1.5 mg/dL	✅ Normal
Uric Acid	7.4 mg/dL	3.4-10.2 mg/dL	✅ Normal (upper limit)

Interpretation:

Renal function is entirely preserved. No evidence of acute kidney injury (AKI).
BUN:Creatinine ratio = 8.88/0.92 = ~9.7, which is within normal (ratio < 20 suggests no prerenal component or upper GI bleed).
Uric acid at 7.4 is within range but at the higher end - worth monitoring.

LIVER FUNCTION TESTS (LFTs)

Parameter	Patient Value	Normal Range	Status
Total Protein	7.0 g/dL	6.3-8.2 g/dL	✅ Normal
Albumin/Globulin	2.04	3.4-4.8 g/dL	⬇️ LOW Albumin
Bilirubin Total	2.1 mg/dL	0.2-1.3 mg/dL	⚠️ HIGH
Bilirubin Direct	0.8 mg/dL	0.1-0.4 mg/dL	⚠️ HIGH - Conjugated
Bilirubin Indirect	1.80 mg/dL	0.1-0.8 mg/dL	⚠️ HIGH - Unconjugated
SGOT (AST)	26 U/L	5-40 U/L	✅ Normal
SGPT (ALT)	57 U/L	5-40 U/L	⚠️ MILDLY ELEVATED
ALK Phos	106 U/L	38-126 U/L	✅ Normal (upper limit)
CGPT (GGT)	Not recorded	12-43 U/L	-

LFT Interpretation:

Mixed hyperbilirubinemia (both direct and indirect elevated) - Total bilirubin 2.1 mg/dL with both fractions raised. This pattern is seen in:
- Typhoid hepatitis (hepatocellular + hemolytic component)
- Early hepatic inflammation
SGPT (ALT) mildly elevated at 57 - indicates hepatocellular injury. AST is normal (26), giving an AST:ALT ratio of ~0.45, pointing to non-alcoholic/viral/enteric cause rather than alcoholic hepatitis (which typically has ratio > 2).
Low albumin (2.04 g/dL) is significantly below the normal range of 3.4-4.8 g/dL. This indicates:
- Possible acute phase reaction (albumin is a negative acute phase reactant)
- Or protein malnutrition
- Or early liver synthetic dysfunction
- In typhoid, albumin can drop due to protein-losing enteropathy and inflammatory response.
ALP 106 is within normal range but toward the upper limit - not suggesting biliary obstruction.
The LFT pattern overall is consistent with typhoid hepatitis - a recognized complication in 1-3% of enteric fever cases, characterized by mild transaminitis, hyperbilirubinemia, and hypoalbuminemia.

WIDAL TEST (CONTEXT)

The sheet title mentions "Widal" investigation. This is a serological test for typhoid fever that detects agglutinating antibodies (O and H antigens) against Salmonella Typhi and Paratyphi.

As per Sleisenger & Fordtran's: "A 4-fold rise in convalescent titer is considered stronger evidence of typhoid fever. Problems with the Widal test include cross-reaction with other Salmonella strains causing false positives." The Widal test results are not recorded on this sheet - they may be on a separate report.

Limitations noted (Red Book 2021): "The CDC does not recommend using serologic tests such as the Widal test to diagnose acute typhoid because these tests are difficult to interpret." Blood culture remains the gold standard.

OVERALL CLINICAL SYNTHESIS

Likely Diagnosis: Typhoid Fever (Enteric Fever) with Typhoid Hepatitis

The constellation of findings strongly supports this:

Finding	Significance
Neutrophilia with relative lymphopenia	Classic in bacterial/enteric infection
Left shift (band cells)	Active bacterial infection
Mildly elevated INR (1.57)	Early hepatic synthetic dysfunction
Mixed hyperbilirubinemia	Typhoid hepatitis (hepatocellular + hemolytic)
Elevated ALT (57), normal AST	Hepatocellular pattern, non-alcoholic
Low albumin (2.04)	Acute phase reaction, inflammatory state
Low-normal sodium (136)	Early/mild SIADH or GI losses
Normal renal function	No AKI - good prognostic sign
Normal platelet count (272)	No thrombocytopenia yet
Widal test ordered	Clinical suspicion of enteric fever confirmed

KEY ABNORMALITIES SUMMARY

🔴 Significantly abnormal:

Albumin 2.04 g/dL (severely low)
Total Bilirubin 2.1 mg/dL (elevated - both fractions)
INR 1.57 (mildly prolonged)

🟡 Mildly abnormal:

SGPT/ALT 57 U/L (mild hepatocellular injury)
Neutrophilia 81.6% with lymphopenia 10.7%
Band cells elevated (left shift)
Sodium 136 mEq/L (low-normal, borderline)

🟢 Within normal limits:

Haemoglobin 14.7, PCV 42.2% - no anaemia
Total WBC 7.39 - no leukocytosis or leukopenia
Platelets 272 - normal
BUN, Creatinine - renal function intact
Na, K, Cl - electrolytes essentially maintained
SGOT/AST 26 - normal
ALP 106 - normal
Total protein 7.0 - normal

MANAGEMENT IMPLICATIONS

Start antibiotics - Ceftriaxone IV (first line for severe typhoid) or oral Azithromycin if mild
Monitor LFTs daily - watch for worsening hepatitis
Serial INR - watch for coagulopathy progression
Strict fluid & electrolyte balance - maintain Na above 135
Repeat Widal titers in 7-10 days if initial titre unavailable
Blood cultures should have been sent before antibiotics - essential for sensitivity
Albumin supplementation consideration if <2.0 g/dL
Avoid hepatotoxic drugs given the hepatitis picture

Sources: Sleisenger & Fordtran's Gastrointestinal and Liver Disease; Park's Textbook of Preventive and Social Medicine; Harrison's Principles of Internal Medicine 22E; Miller's Anesthesia 10e; Textbook of Family Medicine 9e

New ICU Admission ERICU Farida 71/F Came to ER with Generalised weakness since 10days. Fever since 10 days. Unable to walk and decreased responsiveness and decreased urine output since 20 days Patient is not K/C/O HTN/DM/IHD/PTB Hysetrectomy 25 years back On presentation to ER: T - 104 F P - 70 bpm BP-130/70 Spo2-98% on 6Lit o2FM CVS - S1 S2 + RS - B/L BS + Clear PA - Soft and Non Tender CNS-E2V2M4 Bulk- Reduced Tone -normal Power-RUL-2/5,LUL-0/5,RLL-1/5,LLL-1/5 Knee and ankle jerk absent both side. HGT - 156 mg/dl ECG - 2,3,AvF V3-V6 ST depression Labs: Hb/TLC/PLT - awaited Na/K/Cl -175/7.38/145 > 183/3.53/147 Creat - 2.6 LFT -Bil-1.7,OT/PT-130/135,ALP-45 Trop I-0.2 Pt/Inr - 1.42 ABG on 5LO2: Ph - 7.491 Pco2 - 35.6 PO2 - 79.4 HCO3 - 26.6 SO2. - 96.6 Imp: AMS under evaluation

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