clin pharmacy

Lorenzo Llamas Jr. / BS Pharmacy IV / Phar 9b Student 1

UNIT I: INTRODUCTION AND OVERVIEW OF THE COURSE

A. Definition and Scope of Clinical Pharmacy

Defined as the dimension of pharmacy concerned with the science and

practice of rational medication use

Health science discipline in which pharmacist provide patient care that:

o optimizes medication therapy

o promotes health and wellness and

o disease prevention

the practice embraces the philosophy of Health Care or Pharmaceutical Care;

it blends a caring orientation with specific therapeutic knowledge, experience

and judgment for the purpose of ensuring optimal patient outcomes

as a discipline, clinical pharmacy also has an obligation to contribute to the

generation of new knowledge that advances health and quality of life

Clinical Pharmacy encompasses the care for patient in Health Care settings:

they possess in-depth knowledge of medications that is integrated with a

foundational understanding of the biomedical, pharmaceutical, socio-

behavioral and clinical science

To achieve designed therapeutic goals, the clinical pharmacist applies:

o evidence-based therapeutic guidelines,

o evolving sciences

o emerging techniques and

o relevant, legal, ethical, social, cultural, economic and professional

principles

assume responsibility and accountability for managing medication

therapies in direct patient care settings whether practice independent on is

consultative/collaborative with other health care professions

In the USA, physicians do the diagnosis and pharmacists prescribe the

medication. Pharmacists should be familiarized with the different

diagnostic and screening tests and the interpretation of their corresponding

results.


B. Brief History and present status of Clinical Pharmacy

i. International Setting

1928

Pharmacists at the University of Iowa Hospital began

participating in patient rounds

1960 1st use of patient medication profiles in community pharmacy practice was done by Eugene White

1st office-based pharmacy practice opened in Berryville, VA by Eugene White

1962 University of Kentucky Medical Center opened the first

Drug Information Center

1965 University of Iowa Drug Info Service (DIS) was created

1971 University of Missouri – Kansas City began instructing medical students and residents in the safe, effective and

economical use of drugs

1972 Prescribing authority was granted to pharmacists in Indian

Health Service who completed Pharmacist Practitioner Training Program

1974 Pharmacist-conducted drug regimen reviews were required

every 30 days for all residents of skilled nursing facilities

1977 1st Clinical Pharmacokinetic service was recognized by

third-party player

1994 Pharmacists began training to administer immunizations in

Washington State

2001 Pharmacists were represented on epilepsy treatment teams

2004 United Network for Organ Sharing (UNOS) that a

pharmacist be on all transplant teams

2007 IDSA (Infectious Diseases Society of America) recommended that pharmacists be core members of antimicrobial stewardship teams

2008 Pharmacists began serving as medication safety officers

ii. Philippine Setting


1970 – Clinical Pharmacy Practice / Profession started at Makati Medical

Center founded by Dr. Siopin Co

1975 – Dr. Siopin Co’s “Clinical Pharmacy as a set up in a selected

medical center: An Assessment” was published at the Philippine Women’s

University

At present, University of Santo Tomas and Adamson University offer the

1-year post graduate course BS Clinical Pharmacy which includes

advanced internship, clinical experience and immunization

iii. Present Barriers to Clinical Pharmacy

Lack of interest of top management on the concept of higher cost

Other professionals are unhappy

Lack of incentives to pharmacists

Lack of training or specializing areas to develop


UNIT II: CONCEPTS IN CLINICAL PHARMACY

A. Evidence based medicine and therapeutic guidelines

Evidence-based medicine (EBM) emphasizes the use of evidence from

well designed and conducted research in healthcare decision-making. The term

was originally used to describe an approach to teaching the practice of medicine

and improving decisions by individual physicians. Use of the term rapidly

expanded to include a previously described approach that emphasized the use of

evidence in the design of guidelines and policies that apply to populations

("evidence-based practice policies"). It has subsequently spread to describe an

approach to decision making that is used at virtually every level of the healthcare

system.

Whether applied to medical education, decisions about individuals,

guidelines and policies applied to populations, or administration of health services

in general, evidence-based medicine advocates that to the greatest extent possible,

decisions and policies should be based on evidence, not just the beliefs of

practitioners, experts, or administrators. It promotes the use of formal, explicit

methods to analyze evidence and make it available to decision makers. It

promotes programs to teach the methods to medical students, practitioners, and

policy makers.

a. The 5 Step Process of Evidence Based Medication

1. Translation of uncertainty to an answerable question and includes critical

questioning, study design and levels of evidence.

2. Systematic retrieval of the best evidence available

3. Critical appraisal of evidence for internal validity that can be broken

down into aspects regarding:

Systematic errors as a result of selection bias, information bias and confounding

Quantitative aspects of diagnosis and treatment

The effect size and aspects regarding its precision

Clinical importance of results

External validity or generalizability

4. Application of results in practice

5. Evaluation of performance

b. Evidence Reviews


Once all the best evidence is assessed, treatment is categorized as:

1. likely to be beneficial,

2. likely to be harmful, or

3. evidence did not support either benefit or harm.

c. Assessing the Quality of Evidence

From the US Preventive Service Task Force

Level I: Evidence obtained from at least one properly

designed randomized controlled trial.

Level II-1: Evidence obtained from well-designed controlled trials

without randomization.

Level II-2: Evidence obtained from well-designed cohort or case-

control analytic studies, preferably from more than one center or research

group.

Level II-3: Evidence obtained from multiple time series designs with or

without the intervention. Dramatic results in uncontrolled trials might also

be regarded as this type of evidence.

Level III: Opinions of respected authorities, based on clinical experience,

descriptive studies, or reports of expert committees.

d. Therapeutic Guidelines

Reducing Medication Errors

o Read the prescription carefully and thoroughly. If in doubt of the

item, call the doctor to verify before dispensing. Always apply a

system of double checks

o Listen attentively. Certain brand names and generic names sound

alike

o Organize how products are stored in the pharmacy and storage. Use a

systematic labeling system if necessary and store common

medications with uncommonly used strengths/preparations separately

o Maintain a list of potential problematic drugs stored in the pharmacy.

Familiarize the personnel with the list and constantly update the list

1. Medication orders should be complete with regard to patient

information, drug name and dosage. It should be reviewed by the

prescriber for accuracy and legibility immediately after writing.

2. Instructions should be written out rather than using nonstandard or

ambiguous abbreviations

http://en.wikipedia.org/wiki/Randomized_controlled_trial

http://en.wikipedia.org/wiki/Randomization

http://en.wikipedia.org/wiki/Cohort_study

http://en.wikipedia.org/wiki/Case-control

http://en.wikipedia.org/wiki/Case-control


3. Vague instructions, such as “take as directed”, should not be used;

instead, more drug-specific instructions should be taken

4. Exact dosage strength (ex. 20mg) rather than dosage units (ex. 1

tablet) should be specified

5. Exact nomenclature for drug names (nonproprietary or proprietary)

should be used, rather than fabricated drug-name abbreviations

6. A leading zero should always precede a decimal expression of less

than 1 (ex. 0.5mL); conversely a terminal zero should never be used

(ex. 5.0mL), because failure to note the decimal would result in a ten-

fold error. When possible, avoid the use of decimals (ex. Prescribe

500mg instead of 0.5g)

7. The word units (ex. 10 units of regular insulin) should be spelled out

rather than abbreviated with a U, which could be misinterpreted as a

zero (misinterpreted as 100 units rather than the 10 units intended).

8. Use of the metric system should be required.

Medications are not used Correctly when:

o Improper Use – happens when consumers do not understand or

follow directions for taking medications, and often results in serious

consequences. For example, use of non-steroidal anti-inflammatory

drugs (NSAIDs) including aspirin and ibuprofen for pain, without

realizing that improve use of these medications can lead to kidney

failure or gastrointestinal bleeding

o Overuse – happens when too much of the wrong strength of a

medication is taken. For example, most people do not benefit from

taking antibiotics for colds and other respiratory problems, but more

than 23 million prescriptions a year are given to patients for these

conditions. Overuse of antibiotics can lead to drug-resistant strains of

bacteria and potentially life-threatening infections.


o Underuse – happens when a medication is not taken as it should be.

Skipping does of a medication or taking the wrong medication can

ultimately lead to hospitalization or other serious consequences. This

is a growing problem, especially among children. The majority of

medication errors reported in schools are due to children missing

doses.

Useful patient compliance aids

o Labeling – auxiliary labels that provide additional information

regarding the use, precautions and or storage of the medication will

contribute to the attainment of compliance

o Medication Calendars & Drug Reminder Charts – various forms

have been developed and are designed to assist patients in self-

administering drugs to help patients organize their medications and to

monitor self-administration of drugs

o Special Medication Containers, Caps and Systems – special

prescription containers, caps and systems may be effective in

achieving compliance by patients who forget doses or who are

confused by the complexity of the regimen

o Compliance Packing – a compliance package is defined as a

prepackaged until that provides one treatment cycle of the medication

to the patient in a ready-to-use package. It is designed to serve as a

patient-education tool for health professionals and to make it easier

for patients to understand in a ready-use package. It is designed to

serve as a patient-education tool for health-professionals and to make

it easier for patients to understand and remember to take their

medications correctly at home.

o Dosage forms – the development of longer-acting, controlled-release

dosage forms has permitted less frequent administration which

facilitates compliance. The use of transdermal drug delivery systems

permits less frequent administration of medications given by this

route.


Recommendations for Pharmacists to advance prescription compliance

o Become proactive about gathering and providing medicine

information. Ask questions that stimulate dialogue, discuss care plans

with patients and use information about patient to make better

decisions

o Provide compliance monitoring and documentation for at least one at-

risk patient per month. Share findings with the patient and with

his/her other healthcare providers

o Work with management to redesign facilities to increase

pharmacist/patient contact, and to provide a private counseling area.

B. Physical Assessment Skills and Interpretation of Laboratory and Diagnostic Tests

results

a. Physical Assessment Skills

Usual Physical Assessment Sequence

a) Vital Signs

b) Appearance, behavior

c) Skin

d) Head

e) Eyes

f) Ears

g) Nose

h) Mouth

i) Neck

j) Breasts

k) Chest and lungs

l) Heart

m) Abdomen

n) Extremities

o) Back and spine

p) Nervous System

q) Mental Status

r) Genitalia and rectum

ii. Inspection, Palpation, Percussion and Ausculation Techniques

1. Inspection – denotes visual surveillance, i.e., inspect the skin

for color, presence of lesions, visible trauma or abnormalities.

2. Percussion – determines the density of a specific area or part

of the body, create a percussion note either by tapping the body

directly with the distal end of the finger (direct percussion) or

by tapping a finger placed on the body (indirect percussion);

only the finger being struck touches the body. The resultant

sound is described using one of four percussion notes:

resonant, dull, tympanic or flat.


Percussion notes are distinguishable with percussion over areas

of the body that normally produces the notes (percussion over

normal lung tissue produces a dull note; percussion over the

stomach produces and tympanic note; a percussion over large

muscles such as the thigh produces flat notes)

3. Palpation – using hand to feel areas that cannot be seen; can

be performed with the fingertips, palm or back or the hand; use

back of the hand to assess temperature and the fingertips to feel

the lower edge of the liver and the spleen tip.

4. Ausculation – consists of listening either directly with the ear

or indirectly with the aid of a device (typically a stethoscope)

to sounds that arise spontaneously from the body.

iii. Equipments

Equipment Purpose

Flashlight Assess pupillary reflexes; aid in the inspection of the

oropharynxand skin

Ophthalmoscope Perform fundoscopic examination

Otoscope Assess external ear canal and tympanic membrane

Tongue depressor Inspect oropharynx

Watch (digital or sweep

secondhand)

Assess heart and respiratory rate

Thermometer Obtain body temperature

Stethoscope Assess cardiovascular, pulmonary and abdominal

systems

Sphygmomanometer Obtain blood pressure

Reflex hammer Assess neurologic function

Tuning fork Asses neurologic function

iv. Skin

1. Inspection For:

Color (cyanosis, pallor, redness, yellowness)


Lesions

o Describe lesions according to location, type color,

shape, size, grouping and pattern

Trauma

Abnormalities

2. Palpation For:

Turgor (hydration status)

o Pulling up and quickly releasing a fold of skin

o In a well hydrated patient, the skin quickly returns to

normal

o Takes longer for skin to return if patient is dehydrate

Moistness

Temperature (warm, cool)

Texture (rough, smooth)

Thickness (thick, thin)

Mobility (immobile, mobile, hypermobile)

Edema

o Pressing the tips of one or two fingers into the skin and

noting how long the indentation remains after fingers

are removed.

o A plus scale (1+, 2+, 3+, 4+) to quantify edema, with

4+ for most long-lasting indentations


3. Lesions

Primary Lesions

Bulla a large (>1 cm),

circumscribed, elevated lesion containing serous

fluid, such as blistering from second-degree burns

Ecchymosis a large (>1 cm),

hemorrhage, bruise

Macule a small (<1 cm),

circumscribed, flat, discolored lesion, such as

a freckle or flat nevus)

Nodule a large (>1cm) solid lesion

that may be below, even with, or above the surface

of the skin

Papule a small (<1cm), elevated,

solid lesion, wart

Patch an area containing

discolored, circumscribed, and flat or elevated groups

of lesions, measles rash

Petechia a small (<2mm)

hemorrhage Plaque a large (>1cm),

circumscribed, elevated and solid lesion; ex: pityriasis rosea

Pustule a circumscribed, elevated

lesion of varying size containing pus; ex: impetigo

Vesicle a small (<1cm), circumscribed, elevated

lesion containing serous fluid; ex: herpes zoster

Wheal an edematous and transitory papule; ex:

hives Secondary Lesions


Crust mass of dried exudate; ex: impetigo

Excoriation scratch mark usually covered with blood or

serous crusts Fissure linear break in the skin

Keloid hypertrophic scar

Lichenification thickening and roughening

of the skin with increased visibility of normal skin lines

Scale dead epidermal cells; ex: dandruff

Scar area in which normal skin tissue has been replaced

by connective tissue

Ulcer irregularly sized and shaped excavation that

extends below dermal skin layer, ex: pressure sore

Other Lesions

comedo (black head)

pilosebaceous follicular plug of sebaceous and

keratinous material

milium (white head)

small (1-2mm) nodule with no visible opening

nevus (node) flat or elevated pigmented lesion

Osler's node small, raised, discolored, tender lesion on the pads

of the fingers and toes associated with bacterial endocarditis

telangiectasias dilated superficial blood vessels

4. Fingernail and Toenail Terms


Beau's Lines transverse horizontal depressions associated with severe illness

clubbing increased angle (>180 degrees) between the base of the nail and the nail bed; associated

with chronic arterial desaturation (ex: chronic obstructive pulmonary disease [COPD]

koilonychia spooning of the nails associated with iron deficiency anemia

onycholysis separation of the nail from the nail bed associated with trauma, malnutrition and

thyroid disease splinter hemorrhage red or brown linear streaks in the distal

extremity of the nail bed; nonspecific

v. Head and Neck

1. Skull

Inspection: size, contour, shape and evidence of trauma

Palpation: lumps, bumps and evidence of trauma

2. Hair

Inspection: quantity, texture and distribution

Palpation: texture (coarse, fine, dry, oily)

3. Scalp

Inspection: lesions and scales

4. Face

Inspection: expression, symmetry, movement, lesions and

edema

5. Neck

Inspection: symmetry, masses and enlargement of the

parotid and submaxillary gland and lymph nodes.

Note position and size of the sternomastoid muscles and the

carotid arteries and the position of the trachea

Ausculation: enlargement; thyroid bruit may be present

6. Nose

Inspection: symmetry, inflammation and lesions

Transluminate the maxillary sinuses by shining a bright

light in the mouth


Normal maxillary sinuses appear as dull-red crescent-

shaped glowing areas under each eye

Transluminate frontal sinuses by placing a light source

under the medial aspect of each eyebrow.

Normal frontal sinuses appear as glowing red areas above

each eye

7. Ears

Inspection: lesions, trauma, size and countour; edema,

color, insects, discharge, foreign bodies in the canal

Palpation: nodules

8. Hearing

Check hearing using tuning fork in one ear at a time

9. Mouth and Pharynx

Inspection:

o lips and mucosa for color, ulcerations, hydration and

lesions

o teeth and gums for color, bleedings, inflammation,

caries, missing teeth, ulcerations and lesions

o tongue for color, symmetry, ulcerations and lesions

o breath for odor

alcoholic – alcohol intoxication

ruinous – uremia

sweetish – diabetes with ketoacidosis

musty – sever parenchymal liver disease

10. Eyes

Inspection: visual acuity, eye movement, size, color,

lesions, bleeding, specks

11. Terminologies

acromegaly pituitary disorder characterized by amasive face with enlarged lower jaw, prominent nose

and eyebrows, and coarse facial features


astigmatism condition characterized by unequal curvatures of the cornea

AV nicking abnormality visualized on fundoscopic examination associated with hypertension; at

arteriovenous crossings the vein appears to stop abruptly on either side of the arteriole

AV tapering abnormality visualized on fundoscopic examination and associated with hypertension;

at arteriovenous crossings the veins appears to taper off on either side of the arteriole

Bell's palsy unilateral paralysis of the facial muscle

Chvostek sign contraction or spasm of the facial muscles associated with tetany and hypocalcemia;

elicited by tapping the face sharply with a finger just in front of the external auditory

meatus over the facial nerve

conjunctival injection dilated conjunctival vessels

copper wires abnormality visualized on fundoscopic examination and associated with hypertension;

coppery strip of light appears along the vessel

corneal arcus thin, gray-white circle around the cornea; associated with aging

deep hemorrhages abnormality visualized on fundoscopic examination and associated with diabetes;

appears as small irregular red spots in the retina

exophthalmos abnormal protrusion of the eyeball; associated with Grave's disease

fetor hepaticus musty odor of breath associated with parenchymal liver disease

fissured tongue increased tongue fissures; benign; sometimes associated with aging

flame hemorrhage abnormality visualized on fundoscopic examination associated with hypertension;

appears small, linear hemorrhages in the retina

geographic tongue denuded areas of papillae; benign

hairy tongue elongated papillae; benign; associated with antibiotic therapy

hirsutism increased hair growth in androgen-sensitive areas (ex: beard or mustache areas); associated

with ovarian, adrenal, thyroid and pituitary disorders and some medications


hyperopia Farsightedness

Klopik's spots small blue-white spots with red margins found on the mucous membranes near the parotid

duct; associated with measles; appear before skin lesions are visible

microaneurysms abnormality visualized on fundoscopic examination associated with diabetes; appear as

tiny red spots in the macular area

muddy sclera brownish sclera; benign; commonly found in dark-skinned individuals

myopia nearsightedness

normocephalic, atraumatic

physical examination finding meaning that the head is a normal size and shape and no

evidence of trauma is present

palpebral fissure the space, when the eyes are open, between the upper and lower eyelids

periorobital edema puffness of the upper and lower eyelids

Rinne test hearing test that compares air and bone conduction

smooth red tongue finding associated deficiencies of vitamin B12, niacin and iron

Weber's test hearing test that compares bone conduction in both ears

xanthelasma yellow, raised, well circumscribed plaques found in the skin around the eyelids; associated

with hypercholesterolemia

vi. Chest and Lungs

1. Inspection:

chest throughout at least one complete inspiratory-

expiratory cycle

chest wall abnormalities, accessory muscle use, the

anteroposterior diameter, and skeletal abnormalities

2. Percussion:

Intercostals spaces to assess lung density

Percussion over normal lung tissues create a loud, low-

pitched, resonant note

Percussion over areas of lung with increased air volume

(ex: emphysema) creates a very loud, low-pitched, hyper-

resonant note


Areas of consolidation (fluid) produce a dull or flat

percussion note

Shifting dullness is associated with freely moving fluid

within the pleural cavity

Assess all lobes, compare left and right lobes

Determine diaphragmatic location and excursion

Determine location of each diaphragm with lungs fully

expanded and emptied

Normal diaphragmatic excursion is about 3-5cm for

females and 5-6cm for males

Right diaphragm is slightly higher than the left

3. Palpation

Masses, pulsations, crepitation and tactile fremitus

Assess for tactile fremitus, place the palm of the hand on

the chest and have the patient say “ninety-nine” or “one-

two-three”

4. Ausculation

Ausculated with stethoscope

On posterior chest, ausculate between the scapulae and

vertebral column. Place the diaphragm of the stethoscope

flat against the chest wall and instruct patient to breathe

deeply and slowly through the mouth each time the

stethoscope touches skin

Assess at least one complete respiratory cycle over each

anterior and posterior lobe, comparing right and left sides;

assess more thoroughly if abnormalities are detected

Breath sounds are tracheal, bronchial, bronchovesicular or

vesicular

Breath sounds are distinguishable through auscultation over

areas of the lungs that normally produce the sounds

These breath sounds are considered abnormal if heard over

other areas of the lungs

Other abnormal breath sounds include wheezes, rhonchi,

stride and cackles

Pleural friction rub, created when the visceral and parietal

pleural rub together, sounds like creaking leather and is

heard best at the base of the lungs


Voice sounds (egophony, whispered pectoriloquy) are

transmitted more clearly over areas of consolidation; vocal

resonance is decreased over areas of hyperinflation

5. Terminology

apnea absence of respiration

barrel chest anteroposterior diameter ratio of 1:1; associated

with diseases characterized with air trapping; ex: COPD

Biot's respiration irregular respiration; may occur in meningitis

bradypnea abnormally slow respiratory rate with regular

rhythm and normal depth of breathing; associated with CNS (central nervous system) depressants and elevated intracranial pressure

bronchial breath

sounds

loud, high-pitched, normal breath sounds heard

over the manabrium; normal inspiratory/expiratory ration of 1:3

bronchovesicular

breath sounds

normal breath sounds heard over the main stem

bronchi just distal to the central airways softer and lower pitched than tracheal breath sounds with equal inspiratory and expiratory duration

and pitch Cheyne-Stokes

respiration

cyclic, abnormal respiratory patter

characterized by a gradual increase in the depth and rate of respiration followed by a gradual decrease in the depth and rate of respiration

followed by gradual decrease in the depth and rate ending in apnea; characteristic of diseases

that affect the central respiratory centers

consolidation increased density

cackles discontinuous, short-duration, bubbling sounds

crepitation Cackling

dullness or flatness soft, medium-pitched percussion notes elicited

over areas of increase density

egophony altered vocal resonance over areas of

consolidation; the spoken "e-e-e-e" is transmitted as "a-a-a-a"

eupnea normal respiration

funnel chest (pectus

excavatum)

finding in which the lower part of the sternum

is depressed

hypernea increased depth and rate of respiration


hyperresonance loud, low-pitched percussion note elicited over areas of increased air volume

Kussmaul's breathing deep, rapid respiration; characteristic of coma and diabetic ketoacidosis

kyphoscoliosis combined kyphosis and scoliosis

kyphosis abnormal curvature of the spine with backward convexity

pigeon chest anterior displacement of the sternum

pleural friction rub abnormal, creaking leatherlike sound produced when the inflamed surfaces of the visceral and

parietal rub against one another

resonance loud, low-pitched percussion note elicited over normal lung tissue

rhonchi coarse, rattling, abnormal breath sounds; often change location after coughing

scoliosis abnormal lateral curvature of the spine

stridor abnormal, high-pitched, continuous lung sounds heard over the upper airway

tachypnea increased respiratory rate

tactile fremitus palpable vocal vibrations felt through the chest wall; increased over areas of consolidation;

decreased over obstructed areas and pleural abnormalities

tracheal breath sounds

very loud and high-pitched harsh normal breath sounds heard over the extrathoracic trachea

tracheobronchial breath sounds

loud-high pitched, normal breath sounds heard over large bronchi; slight pause occurs between

inspiratory and expiratory sounds; inspiratory duration shorter than expiratory duration

Tympanic loud, drum-like percussion notes elicited over hyper-inflated areas

vesicular breath sounds

slow, low-pitched, normal breath sounds heard over peripheral lung tissue; inspiratory duration

longer than expiratory duration

Wheezes abnormal, high-pitched, continuous breath sounds; associated with airway obstruction

whispered pectoriloquy

whispered voice sounds are transmitted more loudly and clearly than normal; associated with

areas of cavitation and consolidation

vii. Cardiovascular System


1. Inspection:

Chest: Visible cardiac motions

Estimated the jugular venous pressure (JVP

Jugular venous waveforms by observing pulsations in the

jugular vein with the patient supine and head of the bed

elevated to 15 to 30 degrees.

More generally, the right atrial pressure is high

(>15mmHg) if the jugular vein is distended to the jaw

when then patient is seated at a 90-degree angle

2. Palpation

Point of maximal impulse (PMI), local and general cardiac

motion and general cardiac motion and cardiac thrills

PMI normally has a diameter of about 2cm and is located

within about 10cm of the misternal line; use the fingertips

to locate PMI

PMI is easier to identify id the patient sits up and leans

forward than if the patient is supine

Palpate for local and general cardiac motion with the

fingertips with the patient in supine position

Pericardial friction rubs and thrills may be palpable

Radial, carotid, brachial, femoral, popliteal, posterior tibial,

and dorsalis, pedis peripheral pulses

Rate the strength of the pulse as:

o Normal

o Diminished or

o Absent

3. Ausculation

Use stethoscope

Use the diaphragm to assess higher-pitched sounds (S1, S2,

S3, S4)

Peripheral Vascular Pulse Rating Scale

Rating Meaning

0 No pulse palpable

1+ Markedly impaired pulse

2+ Normal pulse

3+ Increased pulse

4+ Bounding (markedly increased) pulse


Apply diaphragm tightly to skin

Great deal of practice and experience is required to identify

and distinguish among the variety of normal and abnormal

heart sounds

Heart sounds are very soft; it may help to listen in a quiet

area or to close the eyes to reduce conflicting stimuli

4. Blood Pressure

Peripheral blood pressure is measured with a stethoscope,

blood pressure cuff and mercury or aneroid

sphygmomanometer

Both types of sphygmomanometers are accurate and easy to

use

The mercury column in mercury sphygmomanometers must

be kept vertical and the meniscus read at eye level.

Aneroid sphygmomanometers must be recalibrated

periodically

Use an appropriately sized cuffs

Cuffs that are too short or too narrow falsely elevate the

blood pressure

Cuff width should be about 40% of the limb circumference

and the cuff length should be about 80% of limb

circumference.

How to measure Blood Pressure:

a) Position cuff correctly

b) Place the arterial portion of the cuff directly over the

brachial artery with the bottom of the edge

approximately 2.5cm above the antecubital crease

c) Palpate for the brachial artery before positioning the

cuff to about 20-30 mmHg over the predicted systolic

blood pressure

d) Deflate cuff slowly (approximately 3mm Hg per

second)

e) There are no audible sounds (Korotkoff’s sounds) until

the cuff pressure approximates the systolic pressure


f) Systolic pressure is the pressure at which at least two

Korotkoff sounds are audible.

g) As pressure falls, the sounds become louder and then

slowly diminish before disappearing altogether

h) Diastolic pressure is the pressure at which the beats are

no longer audible

i) Depending on the clinical situation, it may be necessary

to obtain the blood pressure in both arms or in more

than one body position

j) Do not re-inflate the cuff after partial deflation; cuff re-

inflation causes venous congestion and inaccurate blood

pressure assessments


5. Terminology

bradycardia a slow (<50 beats per minute) heart rate

bruit abnormal ausculatory sound heard over a blood

vessel; associated with turbulent blood flow

crescendo,

decrescendo murmur

murmur that increases and then decreases in

intensity

diastolic murmur murmur heard during diastole

ejection clicks abnormal heart sounds caused by dilation of the

aorta and pulmonary arteries

gallop rhythms exaggerated diastolic heart sounds

holosystolic murmur murmur heard throughout systole

Hypertension elevated blood pressure

Hypotension low blood pressure

midsystolic clicks abnormal heart sounds caused by floppy mitral

valves

opening snap abnormal diastolic heart sound caused by the

opening of a stenotic mitral valve

orthostatic

hypotension

fall in systolic blood pressure of 15mmHg or

more when the patient assumes a more upright position

pansystolic murmur murmur heard throughout systole

pericardial friction rub

abnormal sound created when the visceral and parietal pericardial membranes rub against one another

PMI right ventricular thrust (apical impulse)

pulsus alternans regular alteration of high and low pulse beats; associated with heart failure

pulsus paradoxus decreased systolic blood pressure with inspiration; normally about 5 mmHg

regurgitant murmur murmur produces by backflow of blood across an incompetent valve

S1 first heart sound; produced by mitral and tricuspid valve closure

S2 second heart sound; produced by aortic and pulmonic valve closure

S3 third heart sound; produced by sudden distention of the ventricular wall during ventricular filling; associated with heart failure


S4 fourth heart sound; produced by increased left ventricular end-diastolic pressure and loss of

ventricular distensibility; associated with hypertension

split S2 finding in which both components of the second heart sound (aortic and pulmonic) are

distinguishable; may result from deep inspiration and any disease that delays the

closure of the pulmonic valve

stenosis murmur murmur produced by pathologic narrowing of the orifice of the valve

systolic ejection murmur

murmur produced by increased flow across a normal valve, valvular or subvalvular stenosis;

or other deformity of the valve

systolic murmur murmur heard during systol

tachycardia rapid (>100 beats per minute) heart rate

Thrill palpable variations produced by turbulent blood flow

viii. Breasts and Axillae

1. Inspection:

Breasts with the patient in sitting and supine position:

o Size

o Symmetry

o Contour

o Appearance of the skin

Abnormal findings:

o Visible masses

o Dimpling

o Localized flattening

o Rashes

o Ulcers

o Discharge from nipple

2. Palpation

Nodules, indurations and areas of tenderness or increased

warmth

Axillary lymph nodes, including the pector, subscapular

and lateral groups are located high in the axilla close to the

ribs

Palpate nodes for:


o Size

o Consistency

o Tenderness

3. Terminology

Gynecomastia hypertrophy of breast tissue; associated with

liver cirrhosis, Addison's disease, Klinefelter's syndrome and some medications (ex: spironolactone)

Mastodynia painful breasts

peau d'orange breast skin with an organge-peel appearance

(prominent pores); indication for lymphatic obstruction and is an important sign of malignancy

Retraction dimpling of the skin, nipple retraction or inversion

ix. Abdomen

1. Inspection

Appearance of the skin

umbilicus and

abdominal contour (scaphoid, protuberant)

note: visible aortic and hepatic pulsations, persistent waves,

and fluid shifts

Free fluid in the peritoneal cavity may shift with position,

causing bulging at the flanks when the patient is supine

2. Ausculation

Bowel sounds and abdominal bruits

o Produced by the movement of fluid of air in the bowel,

vary from low rumbles in loosely stretched intestines to

high-pitched tinkling sounds in tightly stretched

intestines


o Normal bowel sounds occur approximately every 10

seconds

o Ausculate for 2 minutes if normal bowel sounds are

present and for 3 minutes if bowel sounds are absent

Quadrant Structure

Right upper quadrant Liver, gallbladder, a portion of the ascending colon, a portion of the transverse colon,

pylorus, duodenum, head of pancreas, right adrenal gland, upper pole of the right kidney

Right lower quadrant Appendix, cecum, portion of the ascending colon, right ureter, lower pole of the right

kidney, bladder (if enlarged), right ovary, right fallopian tube, uterus (if enlarged), right

spermatic cord Left upper quadrant Liver, spleen, stomach, body of pancreas,

portion of transverse colon, portion of

descending colon, left adrenal gland

Left lower quadrant Sigmoid colon, portion of descending colon, lower pole of left kidneyy, left ureter, bladder

(if enlarged), left ovary, left fallopian tube, uterus (if enlarged), left spermatic cord

3. Percussion

Determine liver span and to differentiate between

abdominal fluid and air

Percussion over the liver produces a dull note

Percussion over air-filled loops of bowel produces a hollow

tympanic note

Normal liver span along the right midclavicular is about

10cm

Percuss each quadrant

o Shifting dullness indicated freely moving fluid

o Air-filled loops of bowel float to the surface of the

abdomen and may obscure abdominal fluid

4. Palpation

Palpate tender or rigid areas with light palpation; use pads

of fingertips with light pressure

Use deep palpation to determine the outlines of the

abdominal organs and to assess the size, shape, mobility

and tenderness of the lymph nodes

Palpate all four quadrants


5. Terminology

Ascites free fluid in peritoneal cavity

Borborygmi very loud gurgling and tinkling bowel sounds audible without a stethoscope; associated with

hyperperistalsis

caput medusa dilated veins radiating from the umbilicus; associated with portal vein obstruction

costal margin edge of the lower rib cage

costovertebral angle angle formed by the intersection of the rib cage and the vertebral column

epigastric region upper central abdominal area

fluid wave associated with free fluid in the abdominal cavity

hypogastric region lower central abdominal cavity

Peristalsis circular intestinal contractions that propel the intestinal contents forward

puddle sign gravity-dependent pooling of fluid at the surface of the abdomen

rebound tenderness pain elicited when abdominal hand pressure is abruptly removed; associated with parietal peritoneal membrane inflammation

Rovsing's sign right lower quadrant pain elicited by left-sided abdominal pressure; associated with appendicitis

Scaphoid concave-appearing abdomen

shifting dullness dull percussion notes that shift as the patient shifts position associated with free fluid in the

abdominal cavity

spider telangiectasia (spider angioma)

dilated small surface arteries that appear as small red spots with multiple radiating arms;

associated with portal hypertension

Striae discolored stripes of skin that result from ruptured elastic fibers; striae are pinkish or

bluish when relatively new and more whitish when older

suprapubic region abdominal area just above the pubic arch

umbilical region region around the umbilicus


x. Genitourinary System

1. Inspection

Sacrococcyeal and perianal areas for:

o Lumps

o Ulcerations

o Rashes

o Swelling

o External hemorrhoids

o Excoriations

Female external genitalia:

o Mons pubis

o Labia

o Perineum

o Labia minora

o Clitoris

o Urethral orifice

o Introitus

o For abnormalities:

Lumps

Ulcerations

Rashes

Swelling

Excoriations

Discharge

Female pelvic examination

o Vaginal wall and cervix for color, lesions and shape of

the cervix and cervical os

o Note position of cervix

o Cervical cells may be collected for cytologic evaluation

(Pap smear)

Male external genitalia

o Penis and scrotum

o Contour and abnormalities including lumps,

ulcerations, inflammations, excoriations and swelling

2. Palpation

Anus and rectal walls: tone and tenderness

Prostate: size, consistency and tenderness


Penis: indurations or other abnormalities and palpate the

scrotal structures (testis and epididymis) for size, shape,

consistency, tenderness

Inguinal and femoral areas: bulges that may indicate

hernias

Uterus and ovaries: size, shape, consistency, masses,

tenderness, mobility

Bimanual examination is performed by palpating the

internal structures between a hand placed on the abdominal

wall and a finger placed in the vagina

Combined rectovaginal examination is performed by

palpating the adnexa, cul-de-sac, and uterosacral ligaments

between a finger placed in the vagina and finger placed in

the rectum

3. Terminology

Angiokeratoma red, slightly raised, pipoint benign scrotal lesions; common after age 50 years

anteverted, anteflexed uterus

normal uterine position

Chancre hard infectious venereal ulcer

Chancroid soft infectious venereal ulcer

condylomata acuminatum

venereal warts

Gravid Pregnant

Hernia protrusion of an organ through the muscullar wall that normally contains the organ

Hydrocele serous fluid containing cavity

Papanicolau (Pap) smear

screening technique for cervical carcinoma

prostatic hypertrophy enlarged prostate

Varicocele enlarged spermatic cord

xi. Musculoskeletal System

1. Inspection

Symmetry, proportion, and muscular development

Note: curvature of the spine

Observe gait, stance, ability to stand, sit, rise from a sitting

position, and grasp objects


2. Palpation

Large and small joints

Assess joint range of motion

Decreased range of motion is associated with arthritis,

fibrosis in or around the joint, tissue inflammation around

the joint, and fixed (immobile) joints

Increased range of motion indicates increased joint motility

and may be a sign of joint instability

Assess the areas in and around the joints for abnormalities

such as warmth, tenderness, crepitation and deformities

3. Terminology

ADLs activities of daily living; routine activities

such as getting dressed, cleaning the teeth, combing or brushing the hair, bathing and feeding oneself

bouttonniere

deformity

flexion of the proximal interphalangeal

joint with hyperextension of the distal interphalangeal joint

crepitation audible or palpable crackling sounds

dorsiflexion inward flexion

eversion turning of the toes onto the great toe (foot flexed outward)

extension bending of the joint to bring the joint parallel to the long axis

flexion bending of the joint to bring the parts of joint into close approximation

Gait way a person walks

inversion turning of the toes onto the small toes (foot flexed inward)

kyphosis convex backward spinal curvature

List lateral deviation of the spine

lordosis anteroposterior curvature of the spine ex: accentuation of the normal lumbar curve

neutral range of motion

zero degrees

plantar flexion downward flexion of the foot


radial deviation deviation of the fingers toward the radial bone

rheumatoid nodules firm, nontender, unattached subcutaneous

nodules at pressure points on the extensor of the ulna; association with rheumatoid arthritis

scoliosis lateral curvature of the spine

station way person stands

ulnar deviation deviation of the fingers toward the ulnar

bone

xii. Neurologic System

1. Mental Status

Alertness – determine the patient’s level of consciousness

(awake, alert, confused, unresponsive)

Orientation – determine the patient’s orientation to person,

place, and time. Ask, “what is your name?” “where are

you?” and “what is today’s date?”

Affect – determine the patient’s affect (emotion or mood)

is appropriate to the situation

Speech and Vocabulary – Have the patient say “no ifs,

ands or buts” note patient’s vocabulary throughout the

interview. Ask patient to define a series of increasingly

difficult words

Memory (Immediate, Short-term and Long-term) – to

assess immediate memory, say a list of single-digit

numbers and have the patient immediately repeat the list.

To assess short-term memory, have the patient memorize

three unrelated words. Ask the patient to repeat the words

to ensure that the patient knows the words; then ask the

patient to repeat the words a few minutes later. To assess


long-term memory, ask patient about an age-appropriate,

well-known historical event

Judgment – ask patient to interpret a single problem that

involves judgment such as “what do you do if you noticed a

stamped, addressed envelope on the sidewalk near a

mailbox?”

Abstract Thinking – ask patient to interpret a common

proverb, such as “a bird in hand is worth two in a bush” or

“health is wealth”; ask patient to explain how items are

similar or dissimilar, “what do bananas, apples and oranges

have in common?”

Calculation – ask the patient to perform serial seven

subtractions, starting from 100 (ex: 100 minus 7 is 93, 93

minus 7 is 86, etc); ask patient to spell “world” backward

Object Recognition – ask the patient to identify several

well-known objects (ex: watch, eyeglasses)

Praxis – ask the patient to perform a multistep motor

activity motor activity (ex: pick up a piece of paper with

your left hand, crumple it and hand it to me)


2. Cranial Nerves

Cranial Nerve Function Assessment

I-Olfactory sense of smell evaluate olfactory nerve only if the

patient complains of loss of the sense of smell or if the patient has head injury. Ask patient to close his/her

eyes and identify (one nostril at a time) a familiar odor ex: toothpaste,

soap

II-Optic vision test the patient's visual fields and

ability to discriminate between colors

III-Oculomotor pupillary constriction;

upper eyelid elevation; most extraocular movement

evaluate the oculomotor, trochlear

and aducens nerves [III, IV, VI] (known collectively as ocular nerves) as agrpup. Observe the size and shape

of the pupil, pupillary reaction to light and accomodation and extraocular

movements

IV-Trochlear downward and inward

eye movements

V-Trigeminal temporal and masseter

muscles; lateral movement of the jaw

ask patient to clench teeth; test the

patient's ability to sense stimuli (sharp, dull, hot and cold) over the front half of the head

VI-Abducens lateral deviation of the

eye

VII-Facial facial muscle

movements; sense of taste on anterior two thirds of the tongue

assess motor function, observe facial

movements when the patient frowns, smiles, puffs out of the cheeks, whistles and raises the eyebrows;

assess sensory function, test the patient's ability to identify sweet, sour

and salty solutions placed on the tips of the sides of the tongue

VIII-Acoustic hearing and balance test hearing and balance


IX-

Glossopharyngeal

sensation of the

posterior position of the eardrum, ear, canal,

pharynx, and posterior tongue, including taste; motor activity of the

pharynx

assess quality of speech and the gag

reflex; observe the movement of the soft palate and uvula as the patient

says "aah"

X-Vagus sensation of the

pharynx and larynx; motor function of the palate, pharynx and

larynx XI-Accessory motor function of the

sternomastoid and upper portion of the trapezius muscle

test the patient's ability to shrug his or

her shoulders and turn the chin from side to side against resistance

XII-Hyglossal motor activity of the

tongue

ask the patient to stick our his or her

tongue; note abnormalities such as fasciculations, assymetry, deviations or atrophy

3. Sensory and Motor Function

Assess sensory function by testing the patient’s ability to

detect a variety of sensory stimuli

Ask the patient to close his/her eyes

Start distally and work proximally comparing left and right

sides

Ask the patient to identify when and where he/she is

touched

Use a variety of stimuli, including slight touch, pain and

vibration

Observe the patient for abnormal involuntary muscle

movements, resting muscle tone and strength against

restance

Muscle strength is evaluated using a plus scale, with 0

representing no muscle contraction (complete paralysis) to

5 representing normal muscle strength

Scale Meaning


0 No muscle contractility (complete paralysis)

1+ Barely detectable muscle contractility

2+ Active muscle contractility; unable to work against gravity

3+ Active muscle contractility; unable to work against gravity but not

against resistance

4+ Active muscle contractility; able to work against gravity and some

resistance

5+ Active muscle contractility; able to work against gravity and full

resistance

4. Cerebellar Function

Finger-to-nose test

Hold your finger about an arm’s length in front of the

patient; ask the patient to quickly and repeatedly touch

his or her nose and then your finger

heel-to-shin test

instruct patient to rub the heel down the shin of the

opposite leg

rapid alternating movements

performed by asking the patient to pronate and supinate

the hands rapidly and repeatedly

Romberg test

Performed by instructing patient to stand with the feet

together, arms extended with palms up, and eyes

closed. Patients with normal posterior column function

maintain the position without the moving their feer for

balance

Gait

Ask the patient to walk straight ahead, turn, return

walking on tiptoes, turn, walk away on the heels, turn,

and return walking heel-to-toe; observe the gait

5. Reflexes


Reflex Significance

Babinski's (plantar) extrapyramidal tract pathology

Snout diffuse brain disease

Sucking diffuse brain disease

Grasp prefrontal lobe lesions

Hoffman's corticospinal tract dysfunction

Oculocephalic brainstem pathology

Oculovestibular brainstem pathology

Scale Meaning

0 No response

1+ Diminished response

2+ Normal physiologic response

3+ Increased response

4+ Hyperactive; often associated with clonus

6. Terminology

Abduction movement away from the midline of the body

abstract reasoning ability to think beyond concrete terms

Acalcula inability to calculate

Adduction movement toward the midline of the body

Affect observed motion

Agraphia inability to write

Anosmia complete loss of the sense of smell

Anosognasia inability to recognize one's own impairment

Aphasia inability to speak

Aphonia loss of voice

Asterixis involuntary movements characterized by nonrhythmic flapping of the extremities

Athetosis involuntary movements characterized by slow, twisting irregular motions

Attention ability to focus on one activity

Blocking abnormal thought process characterized by sudden interruption of speech in midsentence


Chorea involuntary movement characterized by brief,

rapid, irregular, jerky motions

Circumstatiality abnormal thought process characterized by

unnecessary detail that delays reaching the point of the thought

Clanging abnormal thought process characterized by the

use of words on the basis of sound instead of meaning

Clonus rhythmic oscillation between extension and flexion

Coma altered state of consciousness characterized by

complete loss of consciousness, unresponsiveness and absence of voluntary

movement Confabulation abnormal thought process characterized by

fabrication of facts or events to fill gaps in the

memory

Confusion abnormality of consciousness characterized by mental slowness, inattentiveness, and incoherent

thought patterns

decerebrate rigidity abnormal body position observed in comatose patients characterized by clenched jaws,

extensions of the neck and legs, adduction of the arms, pronation of the forearms and flexion of

the wrists decorticate rigidity abnormal body position observed in comatose

patients characterized by flexion of the fingers

and wrists and extension and internal rotation of the legs

Delirium abnormality of consciousness characterized by confusion, agitation and hallucinations

Dementia acquired memory impairment

Dysarthria poorly coordinated, irregular speech

Dyscalculia difficulty calculating

Dysgraphia difficulty writing

Dyslexia difficulty reading

Dysphasia hesitancy and error in choosing words when speaking

Dysphonia Hoarseness

Dyspraxia difficulty coordinating body movements

Dystaxia difficulty with muscle coordination

Dystonia abnormal slow, twisting, irregular movements


Echolalia abnormal thought process characterized by

repetition of words or phrases spoken by others

Eversion turning of the toes onto the great toe (foot flexed

outward)

Extension bending of a joint to bring the joint parallel to

the long axis

Fasculation involuntary movements characterized by fine

twitching that rarely moves a joint

Flexion bending of a joint to bring the parts of the joint

into close approximation

flight of ideas abnormal thought process characterized by an

almost continuous flow of accelerated speech with quick changes of subject

Hemianopsia visual field defect associated with disorders of

the optic chiasm or tract

Hemiplegia paralysis of one side of the body

Incoherence abnormal thought process characterized by

illogical connections and quick changes of subject

intention tremor involuntary movements characterized by tremors that are absent at rest but appear with intentional movement

Inversion turning of the toes onto the small toes (foot flexed inward)

Judgment ability to compare and evaluate alternatives

loose associations abnormal thought processes characterized by repeated shifting to unrelated subjects

Mood sustained emotional state

Myoclonus involuntary movements characterized by sudden, brief, unpredictable jerks

Neologism abnormal thought process characterized but the use of invented words or the use of words with new meanings

Nystagmus involuntary oscillation of the eyeball; described as lateral if the eyeball oscillated from side to side, vertical if the eyeball oscillates up and

down, and rotatory if the eyeball oscillates in a circle

ophthalmoplegias optic eye movements

Paraparesis slight degree of lower extremity paralysis

Paraplegia paralysis of the lower extremities and trunk


Perserveration abnormal thought process characterized by

persistent repetion of words or phrases

postural tremor involuntary tremor that occurs when the affected

part maintains position

Pronation to place in a downward-facing position

Quadriplegia paralysis of the upper and lower extremities

recent memory memory of information of a few hours or days

remote memory memory of information from the distant past

resting or static

tremor

involuntary movement at rest

Scotoma a visual field defect associated with disorders of

the optic nerve

Stereognosis ability to identify, by touch, small objects placed

in the hand and physical activity and response to stimuli

Supination to place in a upward-facing position

thought content what a person thinks about

Tics involuntary movements characterized by brief,

repetitive movements at irregular intervals

b. Interpretation of Laboratory and Diagnostic Tests

Screening tests Diagnostic tests

Purpose To detect potential disease indicators

To establish presence/absence of disease

Target

population

Large numbers of asymptomatic,

but potentially at risk individuals

Symptomatic individuals to

establish diagnosis, or asymptomatic individuals with a

positive screening test

Test method Simple, acceptable to patients and staff

maybe invasive, expensive but justifiable as necessary to establish diagnosis

Positive

result

threshold

generally chosen towards high

sensitivity not to miss potential disease

Chosen towards high specificity

(true negatives). More weight given to accuracy and precision

than to patient acceptability

Positive

result

Essentially indicates suspicion of disease (often used in combination with other risk factors) that

warrants confirmation

Result provides a definite diagnosis

Cost Cheap, benefits should justify the costs since large numbers of people

will need to be screened to identify a small number of potential cases

Higher costs associated with diagnostic test maybe justified to

establish diagnosis.


Data from laboratory and diagnostic tests and procedures provide

important information about:

response to drug therapy

ability of patients to metabolize and eliminate specific

therapeutic agents

diagnosis of disease

progression and regression of disease

Laboratory and diagnostic tests are classified as either:

Invasive:

Requires penetration of the skin or insertion of instruments

or devices into a body orifice

Degree of risk involved varies from relatively minor risks

such as pain, bleeding and bruising associated with

venipuncture to the risk of death associated with more

invasive procedures, ex: coronary angiography

Examples: collection of blood, insertion of a central venous

catheter and collection of cerebrospinal fluid

Noninvasive

Do not penetrate the skin or involve insertion of

instruments to body orifices and pose little risk to the

patient

Examples: chest radiograph, analysis of spontaneously

voided urine and stool occult analysis

GENERAL ORGAN SYSTEM MONITORING

LABORATORY TESTS AND DIAGNOSTIC PROCEDURES

Test Description

Angiography Radiographic test used to evaluate blood vessels and the circulation. Radiopaque material is injected through a

catheter and images are recorded using standard radiographic techniques


Biopsy involves the removal and evaluation of a tissue

Computed Tomography (CT

Scan)

Computerized X-Ray system to produce detailed

sectional x-ray images. The system is very sensitive to differences in tissue density and produces detailed, two-dimensional planar images; contrast agents increase

attenuation. The spiral or helical CT takes pictures continuously, decreasing the time needed to obtain

images

Doppler Echography uses ultrasound technology

Endoscopy Examines the interior of a hollow viscus (digestive, respiratory and urogenital organs and the endocrine

system) or canal (bile ducts, pancreas). The endoscope, a flexible or inflexible tube with a camera and a light

source is inserted into a body orifice.

Fluoroscopy Uses a fluoroscope, a device that makes the shadows of x-ray films visible to provide real-time visualization of

procedures; exposes a patient to more radiation than routine radiography but often is used to guide needle biopsy procedures and nasogastric tube advancement

Magnetic Resonance Imaging

(MRI)

Uses an externally applied magnetic field to align the

axis of nuclear spin of cellular nuclei. The patient is surrounded by the magnetic field; brief radiofrequency

pulses are applied to displace the alignment. The energy emitted when the displacement ends is detected, resulting in finely detailed planar and three-dimensional

images; contrast agents increase the attenuation

Plethysmography measures changes in the size of vessels and hollow organs by measuring displacement of air or fluid from a

containment system; used to assess pulmonary function

Positron Emission

Tomography (PET)

Uses positron-emitting radionuclides to visualize organs

and tissues of the body. The radionuclides decay, producing positrons that collide with electrons. A special camera detects photons, released when the positrons and

electrons collide. PET imaging provides quantitative info regarding the structure and function of organs and tissues

Single-Photon Emission

Computed Tomography (SPECT)

Similar to PET but involves the administration of

radionuclides that emit gamma rays. SPECT is less expensive than PET but provides limited image

resolution


Standard Radiography (Plain Films, X-Ray Films)

Produces images on photographic plates by passing X-rays through the body. (these films are sometime difficult to interpret because of the three-dimensionality

is lost on the planar images)

CARDIOVASCULAR SYSTEM

LABORATORY TESTS

Cardiac Enzymes the pattern and time course of the appearance of enzymes in the blood after cardiac muscle cell damage

are used to diagnose myocardial infarction (MI)

Creatine Kinase (CK/Creatine

Phosphokinase)

Found in the skeletal muscle, cardiac muscle and the

brain, bladder, stomach and colon. Isoenzyme fractions identify the type of tissue damaged; detected in the blood

within 3-5 hours after a MI, levels peak in about 10-20 hours and normalize within about 3 days

Cholesterol Separated into lipoproteins by protein electrophoresis. Low-density lipoprotein (LDL) is strongly correlated

with coronary artery disease. High-density lipoprotein (HDL) is inversely correlated with coronary artery

disease

C-Reactive protein Biologic marker of systemic inflammation. Preliminary studies have linked an increased C-reactive protein concentration with an increased risk of MI, stroke, and

peripheral arterial disease

Myoglobin Small protein found in cardiac and skeletal muscle; the presence of myoglobin in the urine or plasm is relatively

sensitive indicator of cellular damage

Triglycerides Found in very-low-density lipoproteins (VLDLs) and

chylomicrons

Troponins Complex of proteins (troponins I, C, T) that mediate the actin and myosin interaction in muscle. Troponins I and

T are specific to cardiac muscle and are used to identify cardiac muscle injury. Troponin I and T concentrations increase within a few hours of cardiac muscle injury and

remain elevated for 5-7 days

DIAGNOSTIC TESTS AND PROCEDURES


Cardiac Catheterization Evaluate cardiac function; a catheter is passed into the right or left side of the heart. Transducers on the tip of the catheter record pressures in the vessels and chambers

of the heart.

Central Line Placement with Hemodynamic Monitoring

A catheter is placed into the central venous system and advanced into the right side of the heart. The right atrial,

right ventricular, pulmonary artery, and pulmonary artery occlusion pressures are measured, and cardiac

output is calculated. These parameters are used to monitor the hemodynamic status of the patient and to calculate the pulmonary and peripheral vascular

resistances.

Chest Radiography Chest x-ray films are used to diagnose cardiac disease and monitor the patient's response to drug and nondrug

therapy; determines the size and shape of the atria and ventricles to calculate the cardiothoracic ratio, and to detect abnormalities in the lung fields and pleural spaces

Cornoary Angiography cardiac vessels are visualized by injecting the vessel with

a contrast agent

Digital Subtraction Angiography (DSA)

background images are obtained before the contrast agent is injected, background images are then subtracted

from the images obtained after the injection of the contrast agent (improves image resolution)

Echocardiography used to evaluate the size, shape and motion of the valves,

septum and walls and changes in chamber size during the cardiac cycle, the beam is applied to the heart through the chest or esophagus

Contrast Echocardiography visualization of the right-sided chambers of the heart is

enhanced by the injection of contrast agents

Doppler Echocardiography evaluate cardiac blood flow patterns

Exercise Echocardiography compares echocardiograms obtained before and during

exercise

Two-Dimensional Echocardiography

(2D Echo) records 2D image of the heart, the spatial anatomic relationships can be determined by changing

the angle of the beam

Electrocardiogram (ECG) records the electrical activity of the heart, diagnose

cardiac disease, monitor the patient's response to drug therapy, and monitor for ADRs


ECG with stress recorded during a standardized exercise protocol with gradually increased levels of exercise or with the patient at rest after the administration of dobutamine or

dipyridamole

Thallium Stress Test Combines the parenteral administration of thallium-201, a radionuclide taken up by healthy myocardial tissue and

the stress test (either exercise or pharmacologic). A gamma camera is used to record serial images of the

myocardium

Intracardiac Electrophysiologic Studies (IEPSs)

tests in which special catheters with electrodes are used to stimulate the cardiac tissue to assess the nature and origin of cardiac arrythmias and the response to anti-

arrythmic drug therapy

Lymphoscintigraphy evaluates the patency and anatomy of peripheral lymph vessels by depositing a radioactive agent in the tissue

drained by the lymph system being evaluated; assesses lymphedema and tumor involvement of regional lymph nodes inaccessible to other imaging procedures

ENDOCRINE SYSTEM

LABORATORY TESTS

Dexamethesone Suppression

Test

Dexamethasone suppresses ACTH (Adenocorticotropic

Hormone) secretion

Human Chorionic Gonadotropin (hCG) test

hCG produced by the human placenta, it is detected in the urine as early as 10 days after missed menstrual cycle

and peaks at about 10 weeks

Insulin Tolerance Test Insulin (0.05-0.1 U/kg) is administered IV, serial blood

samples are obtained for 90 minutes. ACTH is released when the blood glucose falls to less than 40mg/dL

Fasting Serum Glucose test serum glucose concentrations are used to assess pancreatic function and the response to insulin

replacement to insulin replacement therapy; in this test, serum sample is obtained after 10-14 hrs of fasting, usually obtained before breakfast after an overnight fast

Glucose Tolerance test (GTT) used to diagnose diabetes mellitus (DM) and

gestational diabetes


Insulin test fasting serum insulin is sometimes obtained during the assessment of pancreatic function

Lipase test specific marker for acute pancreatic disease; increases in

serum lipase parallel increases in serum amylase, in chronic pancreatitis the pancreas may be "burned out" and unable to secrete lipase

ACTH Stimulation test ACTH stimulates adrenal cortisol production, a baseline

plasma cortisol level is obtained and then 250 mcg of cosyntropin is injected IV, plasma cortisol levels peak in

30-60 mins

Thyroid tests used to establish the level of thyroid function and the response to suppressant evaluating the serum concentrationsof the free hormones thyroxine and

triiodothyronine

GASTROINTESTINAL SYSTEM

LABORATORY TESTS

Alkaline Phosphatase test elevated in biliary cirrhosis, cirrhosis, and intrahepatic

bile duct disease

Direct bilirubin test water-soluble conjugated posthepatic bilirubin, increases with biliary disease

Indirect bilirubin test indirect bilirubin is unconjugated bilirubin, increased

with hemolytic anemia and liver disease

Delta bilirubin albumin-bound conjugated bilirubin, is increased by biliary obstruction and liver disease

Total biliribin sum of all three forms of bilirubin, increased with

hepatic and hemolytic disease


Hepatic Synthetic Function many drugs are hepatically metabolized, one way of assessing the liver's ability to metabolize these agents is to assess the synthetic function of the liver by evaluating

the quantity of specific products produces or processed by the liver

Hepatocellular Enzymes hepatocyte contain numerous enzymes that leak into the

serum when liver cells die or are damaged

Alanine Aminotransferase (ALT)

found in high concentration in hepatocytes and is considered a specific marker of hepatocellular damage

Aspartate Aminotransferase

(AST)

found in hepatocytes, myocardial muscles, skeletal

muscle, the brain and the kidneys, nonspecific marker of hepatocellular damage

Lactic Dehydrogenase (LDH) found in the heart, brain, RBCs, kidneys, liver, skeletal muscle and ileum, elevations occur during shock

syndrome (marked changes in circulation) and diseases associated with hepatocellular damage (hepatitis, cirrhosis, inflammatory disease, and infiltrative diseases)

Stool test Stool is evaluated for color, consistency, and the

presence of obvious or occult blood, fat, ova and parasites, microorganisms and WBCs. The color of the

stool provides diagnostic and monitoring information

Carcinoembryonic Antigen (CEA)

tumor marker found in the blood, associated with rapid multiplication of digestive system epithelial cells and is used to monitor recurrence

DIAGNOSTIC TESTS AND PROCEDURES

Barium Studies patient swallows contrast material and x-ray films are taken to visualize esophagus, stomach and small intestine, barium enemas are used to visualize colon

Capsule Endoscopy relatively new method used to visualize the GIT (gastrointestinal tract), patient swallows a disposable

capsule about the size of a large vitamin tablet that contains a miniature video camera, a light source, a

miniature transmitter an antenna and a battery, images are transmitted to an external receiver in a belt worn around the patient's waist; peristalsis moves the capsule

through the GI system; the capsule is excreted rectally


Cholecytosomography used to detect gallstones and evaluate the gallbladder, biliary system, and adjacent organs

Colonoscopy used to evaluate gallbladder function and anatomy;

orally administered iopanoic acid concentrates in the gallbladder, opacifying it

p-Xylose Test used to screen for carbohydrate malabsorption; a dose of 25g of D-xylose is administered with water and the urine is collected for a 5-hour period; normally more than 3g

of D-xylose is excreted in the urine during this period, lower amounts indicate impaired carbohydrate

absorption

Endosopic Retrograde Cholangiopancreatography

(ERCP) combines endoscopy and x-ray films to visualize the biliary system and pancreas; the endoscope is inserted in the esophagus and advanced to where the

bile ducts and pancreas open in the duodenum; contrast dye is injected into the ducts

Endoscopy flexible fiberoptic tube is inserted orally to visualize the

lining of the upper and lower GI system

Esophagogastroduodenoscopy an endoscope is inserted into the esophagus to visualize the inside of the esophagus, stomach and duodenum

Intragastric pH the pH of gastric secretions is sometimes measured to

monitor the effectiveness of antacid or H2-receptor antagonist therapy

Manometry evaluates esophageal contractions and esophageal sphincter pressures, pressures are measured by pressure

transduces on a tube inserted orally

pH Stimulation tests test involving pH stimulation are sued to determine the

response of gastric acid secretion to a chemical stimulus; they are sometimes used to diagnose hyposecretory and hypersecretory gastric acid disorders. Gastric secretions

are collected from the stomach by aspiration through a nasogastric tube; secretions are collected at baseline and

after stimulation with betazole or pentagastrin

SchillingTest used to evaluate the absorption of vitamin B12 (cyanocobalamin)

Stigmoidoscopy Endoscope is used to evaluate the GIT from the anus to

about 60 cm of the terminal colon. The rigid sigmoidoscope is used to screen for rectosigmoid cancer,


to obtain large mucosal biopsies and to evaluate patients with inflammatory disease of the rectum or distal sigmoid colon

HEMATOLOGIC SYSTEM

GENERAL LABORATORY TESTS

ABO Blood Typing antigen properties of blood are typed to avoid potentially lethal transfusion reactions (Blood types include A, B,

AB, O)

Blood Smear produced by smearing a drop of peripheral blood on a slide and examining the smear microscopically

Coagulation Tests common tests of coagulation include bleeding time,

Bleeding Test duration of bleeding after a standardized skin incision,

used to evaluate platelet quantity and function

Thrombin Time thrombin time is used to evaluate the effect of heparin and thrombolytic drug therapy and coagulation

abnormalities

Cross-matching determines compatibility between donor and recipient

blood, agglutination between the donor's RBCs and the recipient's serum indicates incompatibility

Fibrinogen increased in disseminated intravascular coagulation, used to evaluate bleeding disorders

Fibrin Degradation Products (FDPs) are released when fibrin is broken down,

assessed in the diagnosis and monitoring of disseminated intravascular coagulation

Hemoglobin Electrophoresis immunoelectrophoresis uses electrophoretic separation and immunodiffusion to screen for the presence of

abnormal proteins such as Bence Jones and myeloma proteins.

Serum protein electrophoresis (SPEP) is used to screen for serum protein abnormalities, proteins (albumin, globulin) are identified by different

migration patterns when subjected to an electric field


LABORATORY TESTS BY SPECIFIC CELL TYPE

Platelets initiate hemostasis; risk for spontaneous bleeding is

greatly increased if the platelet count is less than 20,000 cells/mm3; estimated from the peripheral blood smear (manually or electronically)

RBCs

Carboxyhemoglobin Forms in the presence of CO (house fires, smoke). Carbon Monoxide attaches to hemoglobin rendering the

hemoglobin incapable of carrying oxygen

Coomb's test performed by using an antiserum containing antibodies

that act o bridge antibody or complement-coated RBCs; agglutination occurs when the cells are bridged

Eythrocyte Sedimentation Rate

(ESR) is a nonspecific indicator of inflammation, this test measures the rate at which RBCs settle out of mixed

venous blood

Folate decreased serum folate levels are associated with

megaloblastic anemias

Hemoglobin oxygen-carryign RBC protein, reference vary wih age, gender, and elevation above sea level; decreased in

blood loss and iron deficiency anemia, used to diagnose anemia, assess the patient's response to replacement therapy, and estimate oxygen content

Hematocrit the number of RBCs in 100mL of blood reported as a

percentage, reference ranges vary with age, gender ad elevation above sea level, it increased in vitamin B12

and folic acid deficiencies and is decreased in iron deficiency, used to diagnose anemia and assess the patient's response to replacement therapy

RBC Appearance size, shape, and color of RBCs are influenced by many

diseases

Acanthosytes RBCs with long, thin, irregularly placed spines on the membrane, are associated with alcoholic cirrhosis and

heparin therapy and may appear after splenectomy


Anisocytosis variably sized RBCs is associated with early iron replacement therapy

Burr Cells RBCs with evenly distributed spicules on the membrane,

associated with uremia

Elliptocytes rod-shaped RBCs, are associated with sickle cell trait and thalassemia

Hypochromia decrease in the hemoglobin content of RBCs, produces pale RBCs and is associated with folic acid and vitamin

B12 deficiency anemias

Macrocytes larger than normal RBCs

Microcytes smaller than normal RBCS

Normachromia normal RBC color

Ovalocytes oval-shaped RBCs, are associated with microcytic and megaloblastic anemias

Schistocytes RBC fragments, associated with microcytic and

megaloblastic anemias

Spherocytes small, round RBC fragments are associated with anemias and hemolytic transfusion reactions

Stomatocytes RBCs with central slitlike areas of pallor, are associated

with neoplastic, liver and cardiac disease

Target Cells RBCs with dark centers surrounded by light rings are associated with sickle cell anemia, iron deficiency and

liver disease; they also may occur after splenectomy

RBC count the number of RBCSs per 1mL of blood, used to

diagnose anemias, and to assess the patient's repsonse to replacement therapy, serves as an indicator of chronic hypoxemia


RBC inclusions RBCs may contain abnormal material, known as inclusions

Basophilic Stippling fine stippling associated with lead poisoning and some

anemias

Heinz Bodies masses of denatured hemoglobin, are associated with severe oxidative stress and thalassemia

Howell-Jolly Bodies fragments of nuclear DNA that appear as dark purple dots, may occur after splenectomy and also are

associated with hemolyic and megaloblastic anemias

Nucleated RBCs less mature RBCs wih nuclei, are associated with intense narrow eythropoietic activity

RBC indices consist of the mean cell volume, mean cell hemoglobin and mean cell hemoglobin concentration, these are used

to differentiate the type of anemia and to assess the patient's response to replacement drug therapy

Red Cell Distribution Width (RDW) is a histogram of the distribution of RBC

volumes are measured with automated equipment, used to diagnose anemias and to assess the patient's response to replacement therapy

Vitamin B12 decreased vitamin B12 levels are associated with megaloblastic anemias

WBCs a. granulocytes (neutrophils, basophils and eosinophils), b. monocytes and c. lymphocytes

DIAGNOSTIC PROCEDURE

Bone Marrow Aspiration bone marrow is obtained by penetrating the iliac crest or sternum with a large-bore needle and withdrawing a

sample of the bone marrow, the sample is smeared on a slide and evaluated microscopically for cell-line

precursors and iron stores; bone marrow aspiration is used to diagnose anemias and leukemias

IMMUNOLOGIC SYSTEM


LABORATORY TESTS

Antineutrophil Cytoplasmic

Antibodies

(ANCA) are autoantibodes against neutrophil granules

and monocyte lysosomes, p-ANCA reactivity is associated with angiitis, rheumatoid arthritis, inflammatory bowel disease and vasculitis

Antinuclear Antibodies (ANAs) often associated with systemic lupus

erythematosus (SLE), although they may be present in rheumatoid collagen diseases, mixed connective tissue

disease, and systemic sclerosis

Anti-DNA Antibodies Antibodies against double-stranded DNA (dsDNA) and with single-stranded DNA (ssDNA). Anti-dsDNA antibodies often are found patients with SLE

Extractable Nuclear Antigens May be present against specific extractable nuclear

antigens (ENAs). Systemic sclerosis and SLE are associated with high titers of anti-SS-A and anti-SS-B antibodies. Antibodies against histones may be found in

patients with drug-induced SLE

Rheumatoid Factor Against immunoglobulin E and G (IgE and IgM) may be found in patients with rheumatoid arthritis (RA)

Cold Agglutinins antibodies that bind to the surface of RBCs,

agglutination occurs when the blood sample is cooled, associated with a variety of infections and inflammatory disorders

Coomb'sTest uses an antiserum containing antibodies that bridge antibody or complement-coated RBCs; bridging causes agglutination (clumping)

Direct coomb's test uses antibodies directed against human proteins to detect whether these proteins are attached to the surface of

RBCs, used to differentiate between immunologic and non-immunologic

Indirect coomb's test detects antibodies against human RBCs in the patient's

serum, used in cross-matching before transfusion

C-Reactive protein nonspecific indicator of inflammation, is acutely elevated in RA, acute bacterial infections and viral hepatitis and viral hepatitis

Erythtocyte Sedimentation

Rate

(ESR) is a nonspecific indicator of inflammation, this

test measures the rate at which RBCs settle out of mixed venous blood, rate of settling is influenced by the shape of the RBCs and charges on the membrane, a nonspecific


marker of inflammatory and malignant disease

Immunoelectrophoresis uses electrophoretic separation and immunodiffusion

techniques to separate proteins, used to screen for diseases associated with Ig abnormalities

Immunoglobulin E serum IgE is elevated in patients with allergic disorders

Lupus Anticoagulant is a circulating Immunoglobulin found in patients with autoimmune disease, prolongs in vitro clotting time by

inhibiting phospholipid interactions but is not associated with an increased risk of bleeding in vivo

Uric Acid uric acid is the end product of purine metabolism, low

serum levels are associated with Wilson's disease and some malabsorption syndromes, high levels are

associated with rapid cellular destruction (as in chemotherapy or malignancies) and disorders of metabolism as gout

Venereal Disease Research

Laboratory Test

(VDLR) used to diagnose syphilis, is sometimes falsely

positive in connective tissue disease

DIAGNOSTIC PROCEDURES

Allergy Panel Test the patient's reactivity to a variety of antigens

(purified protein derivative antigen, mumps antigen, Streptococcus antigen, Candida, Trichophyton antigen,

histoplasmin); antigens are injected intradermally and the skin is evaluated for redness and swelling at the injection site. Response to one or more of the antigens

indicates a responsive immune system. Response to a specific antigen indicates that the patient has antibodies

to a specific antigen

Scratch or Patch Testing used to evaluate patient sensitivity to specific allergens, each allergen is applied to the skin by scratching the skin; the skin is then evaluated for swelling and redness

INFECTIOUS DISEASE


LABORATORY TESTS

Acid-Fast Stain used to screen for the presence of Mycobacterium,

Nocardia, and Legionella species in body tissues and fluids; some oocytes such as Cryptosporidium can be detected with the acid-fast stain

Cerebrospinal Fluid (CSF)

Analysis

CSF is analyzed for the presence and quantity of RBCs,

WBCs, glucose, and protein; if indicated, stains (Gram's stain and acid-fast stain) and potassium hydroxide and

India ink preparations are used to evaluate the fluid; the CSF glucose is normally about two-thirds the serum blood glucose. Viral meningitis is characterized by a

negative Gram's stain and normal protein and glucose; fungal and tuberculous meningititis is characterized by a

negative Gram's stain, normal protein, and low glucose; bacterial meningitis is characterized by cloudy CSF, increased WBCs, elevated protein and frequently a

positive Gram's stain

Cold Agglutinins antibodies that bind to the surface of RBCs and agglutinate when the blood sample is cooled; about 50%

of patients with Mycoplasma pneumoniae have cold addlutinin titers

C-Reactive protein a nonspecific indicator of inflammation, is acutely

elevated in RA, acute bacterial infections and viral hepatitis; sometimes used to differentiate between bacterial and viral meningitis

Culture and Sensitivity

Testing

cultures of body fluids and tissue identify specific

infecting organisms; in vitro testing is used to determine antibiotic susceptibilities

Gram's Stain evaluates a body fluid or specimen for the presence of microorganisms; organisms are characterized according

to their gram-positive or gram-negative characteristics, morphology and other characteristics

India Ink Preparation used to detect Cryptococcus neoformans in a variety of body fluids; carbons in India ink are unable to penetrate

the organism, enabling the microscopic identification of the organism by its lack of staining

Minimal Bactericidal

Concentration

(MBC) lowest antibiotic concentration that kills at least

9.9% of the bacteria in the original inoculum; used to determine the susceptibility of the organism to

antibiotics


Minimum Inhibitory Concentration

(MIC) lowest antibiotic concentration that completely inhibits the visible growth of a microorganism; determine the susceptibility of the organism to

antibiotics

Potassium Hydroxide Preparation

(KOH) 10-20% is used to detect fungi in body fluids and skin scrapings

Rapid Plasma Reagin Test (RPR test) is used to screen for syphilis; tests for

antibodies against antigens from damaged host cells

Serologic Tests used to indentify an antigen or antibody to help diagnose infectious disease and to monitor the immunologic

response to the microorganism; acute-phase titers and convalescent titers are sometimes compared

Venereal Disease Research

Laboratory Test

(VDLR) used to diagnose syphilis and neurosyphillis,

test for antibodies against antigens from damaged host cells; not as sensitive as RPR test

Wet Mounts body fluid specimensare examined microscopically for the presence of parasites and fungi

WBC Count and Differential the WBC count is often elevated in patients with bacterial and viral infections; a left shift (increased bands

and segmented neutrophils) indicate a bacterial infection; lymphocyte count may be elevated in viral infections;

eosinophil count may be elevated in parasitic infections; elderly patients and those with impaired immune systems or very sever infectious disease may not be able

to mount a white cell response to infection

NEUROLOGIC SYSTEM


Cold Calorics assesses brain stem function in comatose patients; the intact external auditory canal is filled with ice-cold

water; both eyes move toward the cold ear and then snap back to the center if brainstem function is normal

Edrophonium (Tensilon) Test diagnose myasthenia gravis and to determione whether

the maintenance acetycholinesterase inhiitor dosage is appropriate; endrophonium is administered parenterally, and the muscle strength of the patient is evaluated

subjectively


Electroencephalography (EEG) records the electrical activity of the brain from electrodes attached to the scalp; used to diagnose seizures and to assess the patient's response to therapy

Peripheral Nerve Stimulation assesses the depth of neuromuscular blockade

Nerve Conduction Studies rate of nerve conduction is evaluated by stimulating the nerve and recording the rate fo conduction to electrodes placed over the muscle; nerve conduction studies are

used to diagnose nerve injuries and neuromuscular disease

NUTRITIONAL STUDIES

LABORATORY TESTS

Albumin indicator of visceral protein reserves and nutritional

status; protein malnutrition is associated with a serum albumin level of less than 3.5 g/dL if liver function is normal

Bilirubin conjugation of bilirubin requires energy; starvation may

cause mild hyperbilirubinemia

Calcium decreased serum albumin decreases total calcium; the serum calcium does not reflect body stores

Creatinine the 24-hour urinary excretion of creatinine is used to

estimate muscle catabolism; serum creatinine is not a useful indicator of nutritional status, very low serum

creatinine levels may reflect poor nutrional status

Glucose monitored during nutrional supplementation or total nutrional replacement therapy to assess overall metabolic balancel not a useful indicator of nutritional status

Immunologic Status malnutrition may be associated with altered

immunologic status; lymphocyte production may be diminished, resulting in a decreased total lymphocyte count; patients may not be able to mount an

immunologic response to skin test antigens

Magnesium decreased serum albumin levels decrease total magnesium; the serum magnesium does not reflect total

body stores


Partial Thromboplastin Time poor nutritional status may be associated with inadequate intake of vitamin K, resulting in a deficiency of vitamin K-dependent clotting factors and prolonged clotting time

Phosphorus Phosphorus is a metabolic cofactor and intermediate;

refeeding hypophosphatemia may occur in patients with low levels of phosphorus who receive nutritional supplementation or total nutrional replacement therapy

Transaminases starvation compromises cellular membrane integrity and

may be associated with increased transaminases (AST and ALT)

Transferrin Transferrin is an iron transport protein with a shorted half-life than albumin (1week versus 3weeks); serum

transferrin responds more quickly to changes in nutritional status than does albumin and is a useful indicator of nutritional status

Urea Nitrogen, Blood (BUN) is a useful indicator of protein breakdown


Anthropometrics comparative body measurements assess nutrional status; parameters such as skin-fold thickness of the upper

portion of the nondominant arm, midupper arm circumferene (MUAC) and arm muscle circumference

(AMC) are assessed;20%-40% decrease compared with normal values is associated with moderate malnutrition; greater than 40% is associated with severe malnutrition

RENAL SYSTEMS

LABORATORY TESTS

Arterial Blood Gas arterial blood gas assesses acid-base balance and

ventialtion; used to diagnose acid-base disturbances and to monitor the patient's response to drug and nondrug

interventions


Arterial pH arterial pH is a quantitative measure of the degree of acidity or alkalinity of the arterial blood (reference range: 7.35 - 7.45)

Base Excess (BE) is quantitative measurement of the combined

buffering capacity of all body buffering systems, including the bicarbonate system and hemoglobin (-2 to +2)

Bicarbonate Quantitative measurement of net bicarbonate production

and elimination

Carbon Dioxide Tension partial pressure of dissolved carbon dioxide is quantitative measure of net carbon dioxide production

and elimination (35-45 mmHg)

Oxygen Saturation oxygen saturation of the blood (SaO2) is a quantitative

measurement of the percentage of hemoglobin combined with oxygen; can be measured noninvasively with pulse

oximetry

Oxygen Tension partial pressure of oxygen dissolved in the blood is a quantitative measure of oxygen concentration (75-100 mmHg)

Creatinine filtered by glomeruli, is a useful indicator of renal function

Electrolytes and Minerals electrolytes and minerals that are useful when assessing the renal system include calcium, chloride, magnesium, phosphorus, potassium and sodium; the serum

concentration of these electrolytes and minerals is variable and does not reflect total body stores

Calcium (ionized) ionized (free) calcium is the physiologic active portion

of total serum calcium; ionized calcium is used to assess calcium status in patients with or at risk of secondary hyperparathyroidism and in patients with hypomagnesia,

sepsis and pancreatitis (4.6-5.1 mg/dL)

Calcium (total) approximately 40% of serum calcium is bound to albumin in a ratio of 0.8 mg/dL of calcium per 1.0 g/dL

albumin; approximately 15% of serum calcium is bound to albumin; the remaining 45% of serum is unbound ionized calcium; total serum calcium, the sum of bound

and free calcium is used to assess calcium metabolism and to screen for and evaluate the response to therapy in

bone tumors, primary and secondary hyperparathyroidism and hypoparathyroidism, renal failure and acute pancreatitis (8.5-10.0 mg/dL)


Chloride extracellular electrolyte; increased in renal tubular acidosis and primary hyperthyroidism; decreased by the administration of drugs such as thiazide, loop diuretics

and corticosteriods (100-108 mEq/L)

Magnesium intracellular electrolyte; assessment of magnesium deficiency and for monitoring of replacement therapy

(1.5-2.0 mEq/L)

Phosphorus present in bone (about 85% of the total) and skeletal

muscle (about 10% of the total); serum phosphorus concentration is always in a 1:1 ratio with the serum

calcium concentration; used in the diagnosis of hypoparathyriodism and the assessment of bone metabolism (2.5-4.5 mg/dL)

Potassium intracellular electrolyte; serum concentration is sensitive

to changes in acid-base status; increased in acidosis, dehydration and renal insufficiency and with the

administration of some drugs, such as spironolactone; decreased in overhydration and alkalosis and with the administration of drugs such as corticosteroids,

amphotericin, and lithium carbonate (3.5-5.0 mEq/dL)

Sodium extracellular electrolyte; used to assess water and sodium balance, increased in dehydration; decreased in

Addison's disease and by diuretic administration, dilution in ascites, congestive heart failure, renal

insufficiency and excessive water intake (135-145 mEq/L)

Gram's Stain and Culture normal urine contains no bacteriaor yeasts; bacteriaare present in UTIs and pyelonephritis. Gram's stain and

culture identify the cause of the infection and aid in monitoring the patient's response to drug therapy; yeasts

are found in the immunocompromised host and sometimes are associated with braod-spectrum antibiotic therapy

Osmolality measured and compared to assess the kidnet's ability to

concentrate the urine; normal urine-to-serum osmolality ratio is 1:3; Ratios less than 1:1 indicate distal tubular

disease; ratios greater than 1:1 indicate glomerular disease

Blood Urea Nitrogen (BUN) low BUN signify liver disease; high BUN indicated renal disease, other than glomerular function readily affect

BUN levels, sometimes making interpretation of resultant difference

Urinary Sodium differentiate between renal failurefrom prerenal causes

and from parenchymal renal insufficiency; in renal disease the kidneys are unable to conserve sodium,

resilting in elevated urine sodium levels; used to


diagnose the syndrome of inappropriate antidiuretic hormone secretion (SIADH); in SIADH the serum sodium is low but the urine sodium is elevated

Urine Toxicology detect the presence of drugs in patients with suspected

drug overdoses, patients experiencing altered mental status and patients in drug rehabilitation programs

Urinalysis used to screen for renal and nonrenal disease and to monitor the patient's repsonse to drug and nondrug therapy; consists of macroscopic assessment, chemical

screening by dipsteick and microscopic assessment of the urine sedimient

Dipstick Screening

Bilirubin not normally present in the urine; excreted in the urine in the presence of severe liver disease or obstructive biliray

disease; urine appears dark yellow to brown if bilirubin is present

Blood not normally present in the urine; may be visibly be bloody or blood may be found on dipstick examination;

a variety of renal and non-renal diseases including UTIs, renal stones, sickle cell anemia, glomerulonephritis, and

malignant hypertension, are associated with blood in urine

Glucose not normally present in urine; may be present in diabetes miletus

Ketones not normally found in urine; present before serum ketones are detectable in diabetic ketoacids and may be found in patients with who are dieting or are

malnourished

Lueukocyte Esterase not normally found in urine; present in WBCs and may be found in urine during urinary tract and vaginal

infections

Nitrites not normally found in urine; E. converts dietary nitrates

to nitrites are associated with E. coli urinary tract infections but may only be found if the urine is retained in the bladder for at least 4 hours

pH Urinary pH reflects the overall acid-base balance of the

body and the kidney's ability to handle acids and bases; formation of kidney stones is pH dependent. An alkaline

pH (pH .7.0) is commonly associated with the presence of urea-splitting organisms such as Proteus mirabilis


Protein small amounts of protein are normally present in the urine (as much as 0.5g/day); urinary protein is increased in a variety of renal diseases

Specific Gravity reflects the kidney's ability to concentrate urine and the

overall state of hydration; the greater the concentration of the urine, the higher the specific gravity

Urobilinogen not normally present in the urine; may be excreted in the urine in the presence of severe liver disease or obstructive biliary disease

Macroscopic Assessment

Color freshly voided urine is normally pale yellow; normal urine may range in color from nearly colorless if very dilute to orange if very concentrated

Turbidity Freshly voided urine is normally clear; urine is turbid if bacteria, WBCs, RBCs, yeast or crystals are present

Microscopic Assessment

Casts "poor man's renal biopsy" are objects formed and molded within renal tubules; are cylindrical and

composed mostly of protein and cells, may be convoluted (spiral) if formed in distal convoluted

tubules, broad if formed in dilated collecting ducts and narrow if formed in narrow lumens

Bile casts acellular casts that contain bile; associated with liver disease

Hyaline casts acellular casts that consists of a protein matrix; an

occasional hyaline cast may may normally be presen; the number of hyaline casts increases with renal disease

Mixed cellular casts may contain RBCs, WBCs, and renal tubular epithelial cells; are associated with mixed tubular and interstitial

renal diseases

RBC casts RBC casts are formed if the glomerular basement

membrane is damaged; may be found in acute and focal glomerulonephritis, lupus nephritis, and trauma


Waxy casts acellular casts formed by the breakdome of cellular casts; associated wuth chronic renal disease

Cells

RBCs normally, as many as two RBCs per high-power field may be present in the urine; number of RBCs in the urine increases with UTI, stones and tumors and with

strenuous exercise

Renal tubular epithelial cells shed from the renal tubules, are normally present in the urine

Squamous epithelial cells normally present in the urine, shed from the urethra and

vagina

WBCs normally, as many as five WBCs in the urine, increases with renal and urinary tract disease and strenuous

exercise

Crystals found in acidic and basic urine; amorphous phosphate

crystals and triple phosphate crystals, calcium oxalate and uric acid crystals are normally present in acidic urine; a variety of pathologic crystals may be found in

alkaline urine

Bilirubin crystals reddish brown needles, plates and cubes associated with jaundice and bilirubinemia

Cholesterol crystals flat plates with notched corners associated with the

nephrotic syndromes

Cysteine crystals hexagonal plates associated with congenital cystinuria

Leucine crystals round, oily appearing crystals associated with severe

hepatic disease

Tyrosine crystals fine needles grouped in sheaves that are associated with severe hepatic disease



Intravenous Pyelogram (IVP) test used to visualize the entire urinary tract; parenteral

contrast medium cleared by glomerular filtratrion is used to detect ureteral obstruction, masses, tumors and cysts

used to visualize te urine-collecting systems independent of renal function; contrast media are instilled through a catheter placed in the bladder

RESPIRATORY SYSTEM

LABORATORY TESTS

Arterial Blood Gas used to assess the acid-base balance and level of

ventilation, to diagnose acid-base disturbances and to monitor the patient's response to drug and nondrug interventions

Sputum Analysis used to screen for disease and to monitor the patient's

response to drug and nondrug therapy; consists of macroscopic and microscopic assessment

Macroscopic Assessment

Color Normally mucoid and clear; purulent sputum contains

pus and is associated with bacterial infection; yellow sputum is indicative of inflammation. Uniformly rusty-

appearing purulent sputum is indicative of Pneumonococcal pneumoniae pneumonia; bright red streaks in viscid sputum indicates Klesiella pneumoniae

pneumonia. Greenish black sputum is indicative of gram-negative bacilli infection

Odor normal sputum is odorless; foul-smelling sputum is

indicative of a bacterial infection

Viscosity normal sputum is thin and watery, asthmatic patients have a very thick, sticky, tenacious sputum


Volume very little sputum is produced normally; volume of sputum is increased in a variety of diseases including bronchitis, pneumonia, and tuberculosis

Microscopic Assessment

Charcot-Leyden Crystals elongated double pyramid-shaped masses of eosinophils associated with lupus

Curschmann's Spirals casts of small bronchi present in diseases associated with bronchial obstruction, such as asthma

Eosinophils present in asthma and other hypersenstivity disorders

Neutrophils found in bacterial and fungal pneumonia and chronic bronchitis

DIAGNOSTICS PROCEDURES

Bronchoscopy visualize the tracheobronchial tree; flexible bronchoscope is introduced into the tracheobronchial

free through the nose, mouth or endotracheal or tracheotomy tube; samples of fluid and tissue may be

obtained for Gram's stain, culture and cytologic examination

Chest Radiography Chest x-ray films aid in the diagnosis of pulmonary and cardiac disease and the assessment of the patient's

response to drug and nondrug intervention

Pulmonary Function Testing Used to diagnose pulmonary disease to monitor

progression of disease, to predict response to bronchodilators and to monitor the patient's response to

drug and nondrug therapy; performed using a spirometer or body plethysmography. A spirometer detects and records changes in lung volume and flow. Body

plethysmography detects changes in intrathoracic pressure and volume; normal values vary with age,

gender, height, and weight. In general, decreases of 20% or more from predicted values are considered significant


Forced Vital Capacity FVC is the volume of air (in liters) blown out of the lungs during forced exhalation after maximal inspiration

Peak Expiratory Flow Rate PEFR measures the forced expiratory flow in liters per

minute; used to monitor the progression and response to therapy of patients with bronchospastic diseases such as asthma; asthmatic patients monitor their PEFR at home

inexpensive handheld peak flow meters; PEFR variability of greater than 30% indicates moderate to

severe persistent asthma

Tidal Volume (VT) is the volume of air inspired or expired with normal breathing

Pulse Oximetry noninvasive, transcutaneous technique used to assess oxygen saturation

Quanitative Pilocarpine Iontophoresis (Sweat Test)

Concentration of sodium in sweat is measured after stimulation of the sweat glands with topical pilocarpine; low-voltage current is applied to aid in the absorption of

the pilocarpine. The sweat test is used in the diagnosis of cystic fibrosis

Ventilation/Perfusion

Scanning

(V/Q) scanning is used to compare ventilation and

perfusion; images of the airways taken after the inhalation of radiolabeled tracers are compared with images of the pulmonary vasculature taken after the

injection of contrast agents; normally ventilated and perfuse areas match. This test is commonly used to

identify pulmonary emboli

SEROUS BODY FLUIDS

LABORATORY AND DIAGNOSTIC TESTS

Calcium Pyrophosphate Crystals

may be rod-shaped, needle-shaped or rhombic; have positive birefringence and are found intra-cellularly and extra-cellularly; associated with pseudo-gout

Monosodium Urate Crystals needle-shaped, have negative bifringence and are found intra-cellularly and extra-cellularly; associated with gout

1. Biochemical Data


Typical Normal Adult References Values measure in serum

Laboratory test Reference Range

Urea and electrolytes

Sodium 135-145 mmol/L

Potassium 3.4-50 mmol/L

Calcium (total) 2.12-2.60 mmol/L

Calcium (ionized) 1.19-1.37 mmol/L

Phosphate 0.80-1.44 mmol/L

Magnesium 0.70-1.00 mmol/L

Creatine 75-155 mol/L

Urea 3.1-7.9 mmol/L

Estimated glomerular filtration rate (eGFR)

>90mL/min/1.73m2

Glucose

Fasting 3.3-60 mmol/L

Non-Fasting <11.1 mmol/L

Glycated hemoglobin Non-diabetic subjects <42mmol/mol; Inadequate

control >58mmol/mol

Liver function Test

Albumin 34-50g/L

Bilirubin (total) <19 mol/L

Enzymes

Alanine transaminase (ALT) <45U/L

Aspartate transaminase (ASP) <35U/L

gamma-Glutamyl transpeptidase

35-120U/L

Ammonia

Male 15-50 mol/L

Female 10-40 mol/L

Amylase <100U/L

Cardiac markers

Troponin I (99th percentile of upper reference limit) 0.04 mcg/L


Other tests

C-reactive protein (CRP) 0.5mg/L

Osmolality 282-295 mOsmol/kg

Uric acid 0.15-0.47 mmol/L

Parathyroid hormone (adult with normal calcium)

10-65 ng/L

25-hydroxyvitamin D >75 nmol/L (optimal)

>50 nmol/L (sufficient)

30-50 nmol/L (insufficient)

12-30 nmol/L (deficient)

<12 nmol/L (severely deficient)

Water

Water Depletion

Occurs if intake is inadequate or loss excessive

Excessive loss of water through the kidney is unusual except in

diabetes insipidus or overuse of diuretics

Patients with fever will lose water through the skin

Ventilated patients lose it via lungs

Underlying cause for water depletion should be identified and

treated

Replacement of water should be given orally, where possible, or by

nasogastric tube, intravenously or subcutaneously with 5%

dextrose in water or isotonic saline in patients with sodium

deficiency

Water excess

Impairment of water excretion such as caused by renal failure or

syndrome of inappropriate secretion of the antidiuretic hormone

(SIADH)

Chest infections and tumors (small cell carcinoma of the lung)

Cerebral overhydration

Hyponatremia

Excess intake is rare since a healthy adult kidney can excrete water

at a rate of 2mL/min

Sodium (Na+)

Sodium Depletion

Inadequate oral intake is rarely the cause of Na depletion

More common on inadequate parenteral treatment of sodium


Occurs with water depletion, resulting in dehydration

Normal response of the body to the hypovolemia includes an

increase in aldosterone secretion (stimulates renal reabsorption)

Sodium Excess

Can be due to either increased intake or decreased excretion

Excessive intake is not a common cause but can be associated with

excessive intravenous saline depletion due to impaired access to

free water or impair thirst

Usually due to impaired excretion, mineralocorticoid excess

(Cushing’s syndrome or Conn’s syndrome), secondary

hyperaldosteronism ex: congestive cardiac failure, nephritic

syndrome, hepatic cirrhosis with ascites or renal artery stenosis

Hypernatremia

Muscle weakness and confusion

Often drug-induced

Lithium and phenytoin; diabetes insipidus- like syndrome with

lithium has been reported after 2 weeks of therapy, syndrome is

reversible with discontinuation

Demeclocycline can cause diabestes insipidus and can be used

in patients with SIADH

Phenytoin has less pronounced effect on urinary volume than

litium or demeclocycline; inhibits ADH secretion

Hyponatremia

Fall in Na level can result of Na loss, water retention in excess of

sodium resulting from defects in free water

Drugs known to cause hyponatremia

Amitryptyline and other TCAs (tricyclic antidepressants)

Amphotericin

Angiotensin converting enzyme (ACE) inhibitors [Captopril]

NSAIDs (non-steroidal anti-inflammatory drugs)

Opiates

Vincristine

Potassium

Hypokalemia

Moderate hypokalemia may be asymptomatic

Severe hypokalema = muscle weakness, hypotonia, paralytic ileus,

depression and confusion, arrhythmias

Drugs known to cause hypokalemia: ampotericin, aspirin,

corticosteroids, insulin, laxatives, diuretics (except K-sparing),

sodium bicarbonate, sodium chloride, penicillin G, salicylates


Hyperkalema

May arise from excessive intake, decreased elimination or shift of

potassium from cells to the extracellular fluid (ECF)

Hyperkalemia can be asymptomatic but fatal

An elevated potassium level has many effects on the heart: notably

resting membrane potential is lowered and action potential

shortened

Calcium

Hypercalcemia

May be caused by variety of disorders, most common being

primary hyperparathyroidism

Thiazide diuretics, lithium, tamoxifen and calcium supplements

used in management of osteoporosis are examples of some drugs

that cause hypercalcemia

Hypocalcemia

Caused by a variety of disorders including severe malnutrition,

hypoalbuminemia, hypoparathyroidism, pancreatitis and those that

cause vitamin D deficiency

Drugs that cause hypocalcemia include: bisphonates, phenytoin,

Phenobarbital, aminoglycosides, phosphate edemas, calcitonin,

cisplatin, mithramycin and furosemide

Phosphate

Hypophosphatemia

Severe cases can cause general delebility, anorexia, anemia,

muscle weakness and watering and some bone pain and skeletal

wasting

Inadequate phosphorus intake requires near starvation

Hyperphosphatemia

Occurs in chronic renal failure

Less common causes are secondary to rhabdomyolysis, tumor lysis

or severe hemolysis and hyperphosphatemia

Magnesium

Hypomagnesemia

Frequently seen in critically ill patients

Causes include: excess GI (gastro-intestinal) losses, renal losses,

surgery, trauma, infection, malnutrion and sepsis


Drugs that induce hypomagnesemia include: amikacin,

amphotericin B, cisplatin, gentamicin, tacrolimus, carboplatin,

digoxin

Hypermagnesemia

Caused by renal insufficiency and excess iatrogenic magnesium

administration

Creatinine

Good indicator of the glomerular filtration rate (GFR)

Serum creatine can be transiently elevated by meat ingestion, urea or

strenuous exercise

Overall measure of kidney function

Allows estimation of GFR

Urea

Elevation of serum urea

High protein intake from diet

Tissue breakdown

Major hemorrhage in the gut

Consequent absorption of the protein from blood

Corticosteroid therapy

Production is decreased where there is a low protein intake and in

some patients with liver disease

Glucose

Normal ranges for serum glucose for nonfasting: <11.1 mmol/L;

fasting: 3.3-6.0mmol/L

Fasting serum glucose levels between 6.1 – 7.0 mmol/L indicate

impaired glucose tolerance

Fasting serum glucose levels above 7.0 mmol/L indicate diabetes

Uric acid

Elevated serum nitric acid level

Increased rate of formation

Reduced excretion

2. Liver Function Tests

Albumin

Low serum concentration

Volume of albumin increases

In cirrhosis with ascites, fluid retention such as pregnancy

Bilirubin

Elevation of serum bilirubin

Reveal as jaundice, seen best in the skin and sclera


Caused by increased production of bilirubin (ex: hemolysis,

ineffective erythropoesis), impaired transport into hepatoctes

Enzymes

Alkaline phosphatase (ASP)

Enzyme which transports metabolites across cell membranes

Pathological increase in serum ASP

Caused by: disorders of the liver ex: hepatitis, drug-induced ex:

ACE inhibitors, estrogens; pregnancy; osteomalacia

Transaminase

Elevated serum AST

Variety of disorders including liver diseases, crush injuries, severe

tissue hypoxia, myocardial infarction, surgery, trauma, muscle

disease pacreatitis

Elevated serum ALT

Similar to agents that caused serum AST elevation but at a lesser

extent

Raised by viral and non-viral acute and chronic liver disease, drug

induced (ex: paracetamol poisoning), alcohol and ischemic liver

damage

Gamma-Glutamyl transpeptidase (Gamma GT)

Elevated levels in alcoholic liver disease, hepatitis, cirrhosis and non-

hepatic disease such as pancreatitis, congestive cardiac failure, COPD

and renal failure

Ammonia

Hyperammonemia occur at concentrations >60 mmol/L

Clinical features: anorexia, irritability, lethargy, vomiting,

somnolence, disorientation, asterixis, cerebral edema, coma and death

Cause include: genetic defects in urea, hepatic dysfunction

Amylase

Produced in the pancreas and salivary glands

Serum amylase elevation

Caused by pancreatitis

Loss of bowel integrity though infarction

Perforation

chronic alcoholism

post-operative states and

renal failure

3. Hematology data


Hemotology Data: Typical Normal Adult Reference Values

Hemoglobin 11.5 - 16.5 g/dL

Red Blood Cell (RBC) count 3.8 - 4.8 x 1012/L

Reticulocyte count 50 - 100 x 106/L

Packed cell volume (PCV) 0.36 - 0.46 L/L

Mean cell volume (MCV) 83 - 101 fL

Mean cell hemoglobin 27-34 pg

Mean cell hemoglobin concentration (MCHC)

31.5 - 34.5 g/dL

White Blood Cell Count 4.0 - 11.0 x 109/L

Neutrophils (30-75%) 2.0 - 7.0 x 109/L

Lymphocytes (5-15%) 1.5 - 4.0 x 109/L

Monocytes (2-10%) 0.2 - 0.8 x 109/L

Basophils (<1%) <0.1 x 109/L

Eosinophils (1-6%) 0.04 - 0.4 x 109/L

Platelets 150 - 450 x 109/L

Erythrocyte Sedimentation Rate (ESR)

1 - 35 mm/h

D-dimers 0 - 230 ng/mL

Ferritin 15 - 300 mcg/L

Total iron binding capacity (TBC)

47 - 70 mol/L

Serum B12 170 - 700 ng/L

Red cell folate 160 - 600 mcg/L

Iron 11 - 29 mol/L

Transferrin 1.7 - 3.4 g/L

RBC count

High RBC count (erythrocytosis or polycythemia) = increased

production by bone marrow, response to hypoxia; malignant condition

of red cells such as in polycythemia rubra vera

Reticulocytes

Assessing response of the marrow to iron, folate or vitamin B12

therapy (count peaks at about 7-10 days after starting such therapy and

then subsides)

Mean Cell Volume (MCV)


Useful in the process of identification of various types of anemias such

as caused iron deficiency (microcytic) or vitamin B12 or folic acid

deficiency (megaloblastic or macrocytic)

Packed Cell Volume (PCV)

Ratio of volume occupied by RBCs to the total volume of blood

Measured by centrifugation of a capillary tube and then expressing the

volume packed in the bottom as a percentage

Calculated as product of MCV and RBC and reflects RBC

Low values = anemia; raised values = polycythemia

Mean Cell Hemoglobin (MCV)

Dependent of the size of the RBCs and concentration of hemoglobin in

cells

Usually low in iron-deficiency anemia

Raised in macrocytic anemia

Mean Cell Hemoglobin Concentration (MCHC)

Measure of average concentration of hemoglobin in 100ml or RBCs

Expressed in gram per liter

Low MCHC values in iron-deficiency anemia

High MCHC values in prolonged dehydration

Platelets

Thrombocytosis = low levels of platelets; occurs in pregnancy, viral

infections, spontaneous bleeding, intravascular coagulation

Thrombocytosis = high levels of platelets; occurs in malignancy,

inflammatory disease and in response to blood loss

White Blood Cell Count

Neutrophils / Polymorphonucleocytes (PMNs)

Most abundant type of WBC

Have phagocytic action

Counts increase (Neutrophilia) in: infection, tissue damage

(infarction) and inflammation (ex: acute gout)

Neutropenia (decrease in neutrophils) is associated with

malignancy and drug toxicity; also occur in infections such as

influenza, infectious mononucleosis and hepatitis

Basophils

Normally constitute small percent of WBC count

Elevated numbers (basophilia) occur in various malignant and

premalignant disorders ex: leukemia and myelofibrosis

Eosinophils

Constitute 6% of WBCs

Acts in inactivation of mediators released from mast cells


Eosinophilia is apparent in allergic reactions such as asthma, hay

fever; worm infestation and drug sensitivity

Lymphocytes

2nd most abundant WBCs

Formed in bone marrow

Increase in lymphocyte occurs particularly in viral infections such

as rubella, mumps, infectious hepatitis and infectious

mononucleosis

Monocytes

Increased in infections ex: typhpoid, subacture bacterial

endocarditis, infectious mononucleosis and tuberculosis

Coagulation

Process by which a platelet and fibrin plug is formed to seal a site of

injury or rupture in a blood vessel

4. Monitoring anticoagulant therapy

One stage Prothrombin Time (PT)

Measuring the PT is the most commonly used method for monitoring

oral anticoagulation activity

PT is responsive to depression of three of the four vitamin K

dependent factors (II, VII and X)

PT is measured by adding calcium and thromboplastin (phospholipid-

protein extract of tissue that promotes the activation of factor X by

factor VIII) to citrated plasma

International Normalized Ratio (INR)

Results are expressed as a ratio of the PT time of the patient compared

with that of the normal control

D-dimers

Degradation products of fibrin clots

formed by the sequential action of three enzymes = thrombin, factor

VIIIa and plasmin; which degrades cross-linked fibrin to release fibrin

degradation products and expose the D-dimer antigen

Xanthochromia

Yellow discoloration of cerebrospinal fluid caused by hemoglobin

catabolism

Arise within several hours of subarachnoid hemorrhage (SAH) and can

help to distinguish the elevated red cell count observed after traumatic

lumbar puncture from that observed following SAH

Spectrophotometry – detects the presence of both oxyhemoglobin and

bilirubin which contribute to xanthochromia

Iron, transferring and iron binding


Iron important in production of hemoglobin and myoglobin

Iron circulating in the serum is bound to transferring

Leaves the serum pool and enters the bone marrow where it becomes

incorporated into hemoglobin in developing red cells

Serum iron levels are extremely labile and fluctuate throughout the day

and provide little useful info about iron status

Iron balance is regulated by hepdicin, a circulating peptide hormone,

which aims to provide iron as needed, while avoiding excess iron

promoting formation of toxic oxygen tradicals.

Iron overload causes high concentrations of serum ferritin as can liver

disease and some forms of cancer

Vitamin B12 and folate

Liver disease tends to increase B12 levels and may be reduced in folate

deficient patients

Malabsorption of B12 may result from long-term ingestion of antacids

such as proton pump inhibitors or H2-antagonists or biguanides

(metformin)

Serum folate levels tend to increase in B12 deficiencies and alcohol

can reduce levels

C. Complimentary and Medicinal Interventions

a. Alternative Medical Systems

Alternative medical systems are built upon complete systems of theory

and practice. Often, these systems have evolved apart from and earlier than the

conventional medical approach used in the United States. Examples of alternative

medical systems include: Acupuncture, Ayurveda, Homeopathy.

b. Mind-Body Interventions

Mind-body medicine uses a variety of techniques designed to enhance the

mind's capacity to affect bodily function and symptoms. Some techniques that

were considered alternative in the past have become mainstream (for example,

patient support groups and cognitive-behavioral therapy).

c. Biologically-based Therapies

Biologically based therapies in complementary and alternative medicine

use substances found in nature, such as herbs, foods, and vitamins. Some

examples include: Diet, Dietary supplements

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D. Therapeutic planning and patient counseling

a. Therapeutic Planning/ Drug Use Process

i. Need for a Drug

Ensure there is an appropriate indication for each drug and

that all medical problems are address therapeutically

ii. Select drug

Select a recommend the most appropriate drug based upon

the ability to reach the therapeutic goals

iii. Select regimen

Select the most appropriate drug regimen for

accomplishing the therapeutic goals

iv. Provide drug

Facilitate dispensing of the drug and ensure the drug is

accurately prepared and delivered to the right patient and

administration site and time basis

v. Drug administration

Ensure that appropriate devices and techniques are used for

drug administration

vi. Monitor drug therapy

Monitor drug therapy for effectives or adverse effects in

order to determine to maintain, modify or discontinue

vii. Counsel patient

Educate patient or caregiver about the patient’s therapy to

ensure proper use of medicines

viii. Evaluate effectiveness

Evaluate patient’s drug therapy by reviewing previous steps

of the drug use process and take appropriate steps to ensure

the therapeutic goals are achieved.

b. Patient Counseling

i. Exercise active listening

Allow patient to state the problem completely, and the

pharmacist should provide undivided attention to minimize


misperception and misunderstanding. Then the pharmacist

must be able to summarize mentally what the patient has

said and provide positive feedback that conveys

understanding of the problem

ii. Question the patient thoroughly

The patient often provides incomplete or contradictory

information, with experience, the pharmacist should be able

to gather the needed information in a period of minutes.

This will be easy if the proper medications are asked to the

patient. If the situation is more complex and time-

consuming, the pharmacist can ask the patient to return at a

mutually agreeable time, contact them by telephone or refer

directly to physician

iii. Interpret verbal and nonverbal communication

Every question asked to the patient should be phrased

carefully to facilitate interpretation. The pharmacist should

be able to convey his interest to be of help to the patient. It

is important to be aware of the patient’s nonverbal cues.

The pharmacist should assess the patient physically,

through observation or inspection. This would provide

clues to the overall state of health of the patient, and these

provide insight to the seriousness of the problem.

E. Monitoring of Drug Therapy and Utilization

Patient Monitoring Format

Current Medications

Start Date Medication/

Route

Dose/Schedule Stop Date Start Date

F. Monitoring and Report of Adverse Drug Reactions and Interactions

Several countries in the world conduct national reporting programs for ADRs. Most programs rely on voluntary reporting by physicians, and in some

cases, reporters are appointed to coordinate this activity in hospitals. This is one


of the responsibilities of the PTC (Pharmacy and Therapeutics Committee). However, a subcommittee can be organized to work closely with the PTC.

The PTC should be the repository for adverse drug reaction reports since the committee is the one responsible for accepting and deleting drugs in the

hospital formulary. As such, the committee should be provided with continuing feedback of significant drug therapy problems in the hospital. These reports can in turn be reported to the entire medical staff through the

pharmacy bulletin or other hospital publications. Problems related to drug administration can be solved through close coordination with the nursing staff in

establishing parameters for monitoring drug therapy, collaborating in-patient education and discharge planning, and providing routine drug information.

G. Drug Use Review

With the abundance of drug products which do not reflect the actual health

needs of patients in hospitals and considering the limited financial and manpower resources, it is important to improve the quality ofdrug usewithin a health care

organization. The development of an evaluation process would lead to corrective measures in drug utilization for patients and reduction in cost of care.

Drug utilization is defined as an authorized, structured, and continuing program which reviews, analyzes and interprets patterns of drug use in a given

health care delivery system against a predetermined standard. The predetermination of standards of care provides both scientific validity to the work and acceptability by the hospital staff.

H. Monitoring and Reporting of Medication errors and Pharmacovigilance

consideration

If an error occurs in the administration or application of medication, the proper official should be informed immediately. Medication errors should not be

discussed with the patient. A detailed account of the error, whether of omission or commission, should be prepared with duplicate and forwarded to the proper official.

I. Pharmacoeconomics

Pharmacoeconomics refers to the scientific discipline that compares the value of one pharmaceutical drug or drug therapy to another. It is a sub-discipline of health economics. A pharmacoeconomic study evaluates the cost (expressed in

monetary terms) and effects (expressed in terms of monetary value, efficacy or enhanced quality of life) of a pharmaceutical product. There are several types of pharmacoeconomic evaluation: cost-minimization analysis, cost-benefit

analysis, cost-effectiveness analysis and cost-utility analysis. Pharmacoeconomic

http://en.wikipedia.org/wiki/Health_economics

http://en.wikipedia.org/wiki/Quality_of_life

http://en.wikipedia.org/wiki/Cost-minimization_analysis

http://en.wikipedia.org/wiki/Cost-benefit_analysis

http://en.wikipedia.org/wiki/Cost-benefit_analysis

http://en.wikipedia.org/wiki/Cost-effectiveness_analysis

http://en.wikipedia.org/wiki/Cost-utility_analysis


studies serve to guide optimal healthcare resource allocation, in a standardized and scientifically grounded manner.

One important consideration in a pharmacoeconomic evaluation is to

decide the perspective from which the analysis should be conducted (such as

institutional or societal).

J. Dose adjustment

Under most circumstances provided the preceding criteria observed, adjusting the

dose of a drug is relatively simple, since a linear relationship exists between the

dose and concentration if a drug follows firs-order elimination

a. Factors involved:

i. Patient factors (ex: severity of disease, age)

ii. Concentrations achievable at the site of action

iii. Level of sensitivity to the drug

b. Criteria

i. Capacity limited clearance

If a drug is eliminated by the liver, it is possible for the

metabolic pathway to become saturated, since it is an

enzymatic system

Initially, elimination is the first-order, but saturation of the

system occurs, elimination becomes zero-order.

For the majority of drugs

ii. Increasing clearance

iii. Therapeutic clearance

c. Dose Calculations

i. Young’s rule:

Age X Adult dose = dose for child

Age + 12

ii. Cowling’s rule

Age at next birthday (in years) X Adult dose = dose for child

24

iii. Fried’s rule for infants:

Age (in months) X Adult dose = dose for child

http://en.wikipedia.org/wiki/Perspective_(pharmacoeconomic)


150

iv. Clark’s rule:

Weight in pounds X Adult dose = dose for child

150

v. Dose Based on Body Weight

Patient’s weight (kg) x Drug dose (mg) = Patient’s dose (mg)

1(kg)

vi. Dose Based on Body Surface Area (BSA)

Patient’s BSA = √ (Patient’s height (cm) x Patient’s weight (kg)

3600

Patient’s BSA (m2) X Drug dose (mg) = Patient’s dose (mg)

1.73m2

K. Nutrition

Nutrition is the act or process of being nourished.


UNIT III: Disease Orientation and Management

A. Definition

B. Classification

C. Etiology

D. Clinical features

E. Treatment and monitoring

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clinical science

scope of clinical pharmacy

health care settings

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philosophy of health

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