interpretation of routine laboratory investigations in general practice
TRANSCRIPT
Interpretation ofRoutine Laboratory Investigationsin General PracticeDr.Jithesh.K,MD (General Medicine)
Senior Consultant Physician
STARCARE HOSPITAL,KOZHIKODE
We were taught and
there are evidences,
which show that a good
Case History and a
thorough Clinical
examination usually
reveals most ,if not all of
clinically relevant data.
BUT…..
There remains a need to confirm/document our clinical
impression though, due to present trends of EBM and the
Medico-Legal environment.
Lab investigations supplement rather than replace other methods
for gathering information.
It is a known fact that with the help of lab investigations, some
underlying systemic conditions of which the patients(or even
doctors) are unaware of, are often identified in General practice
for the first time.
Is there a ROUTINE for
Laboratory investigations in all patients ?
NO,BUT THE LAB TEST YOU SELECT IN YOURCLINICALPRACTICE SHOULD HELP TO…
Confirm or reject your clinical diagnosis.
Provide suitable guidelines in your patient management.
Provide prognostic information of the diseases under your
consideration.
Detect diseases through case-finding screening methods.
Establish normal baseline values before treatment.
Monitor follow up therapy.
Provide information for Medico-Legal consultations.
On what basis should I select my Routine lab investigations in my General
practice?
Accuracy
Cost effectiveness
Interfering factors
Morbidity
Reference Range
Specimen collection
Sensitivity
Specificity
SENSITIVITY
(SCREENING)
The probability that a patient with disease has positive test
SPECIFICITY
(DIAGNOSTIC)
The probability that a healthy patient has a negative test
Is Blood routine examination and
Urine routine examination a
ROUTINE laboratory
investigation?
NO
• Hb
• RBC
• TC
• DC
• PLATELET COUNTBlood routine examination is better called Complete blood count(CBC).
• Urine macroscopy
• Urine microscopy
• Urine chemical tests
Urine routine examination is better called urine analaysis.
What are the Routine Laboratory investigations used by a General Practitioner that are going to be discussed here ?
Primary discussion
Complete Blood Count(CBC)
ESR
Blood Sugars
Urine analysis
Renal Function Tests(RFTs)
Liver Function Tests(LFTs)
Addendums
Peripheral smear
CRP
HBA1C
Uric acid
Prothrombin time
Why ?
Correct interpretation of these routine laboratory investigations usually directs the General practitioner to the right diagnosis in daily practice!!
RIGHT DIAGNOSIS
COMPLETE BLOOD COUNTS (CBC) or HEMOGRAM
+PERIPHERAL SMEAR
(Treasure trove for diagnosis of so many Hematological and Non hematological diseases)
Hemoglobin(Hb)
RBC counts
Total WBC counts(TC)
Differential WBC counts(DC)
Platelet counts(Plt)
Hematocrit(PCV, Packed cell volume)
Mean corpuscular volume(MCV)
Mean Corpuscular Hemoglobin(MCH)
Mean Corpuscular Hemoglobin concentration(MCHC)
COMPLETE BLOOD COUNT (CBC)
Normal Values
HEMOGLOBIN(12-15gm/dl)
IF LOW HEMOGLOBIN (ANAEMIA)
MCV
LOW (MICROCYTIC)(<85fl)
NORMAL (NORMOCYTIC)(85-100fl)
HIGH (MACROCYTIC)(>100fl)
IF HIGH HEMOGLOBIN(POLYCYTHAEMIA)
ERYTHROPOETIN
LOW (POLYCYTHAEMIA-VERA)
HIGH(SECONDARY POLYCYTHAEMIA)
CAUSES OF ANAEMIA BASED ON MCV
CAUSES OF POLYCYTHAEMIA(PCV/HEMATOCRIT >55%)
NORMAL ERYTHROPOEITIN
Total WBC count (TC)(5,000-10,000/mm3)
>10,000/mm3 <5,000/mm3
Differential count (DC)
Neutrophils(60-70%) or (3000-
7000/mm3)
Lymphocytes(20-30%) or (1000-
4000/mm3)
Eosinophils(1-3%) or (50-400/mm3)
Basophils (0.3-0.5%)and
Monocytes(3-8%)
Interpretation of the Neutrophil count
Interpretation of Neutrophil count
Interpretation of Lymphocytic count
The ALC can then be calculated by multiplying the WBC and the percentage of lymphocytes:
ALC (cells/microL) = WBC (cells/microL) x percent lymphocytes ÷ 100
Reactive/clonal/malignant — Lymphocytosis can be either a reactive polyclonal proliferation or a clonal expansion.
Causes of Lymphocytosis
Reactive
Acute viral infections (e.g., hepatitis, chicken pox, cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes, rubella)
Certain bacterial infections (e.g., Enteric fever, pertussis (whooping cough), tuberculosis (TB))
Clonal
Acute/Chronic Lymphocytic Leukemias
Lymphomas
Causes of Lymphocytop-enia
Autoimmune disorders (e.g., lupus, rheumatoid arthritis)
Infections (e.g., HIV, TB, hepatitis, influenza)
Bone marrow damage (e.g., chemotherapy, radiation therapy)
Immune deficiency
Interpreting Eosinophil,Monocyte and Basophil counts
Interpretation of Platelet counts
Thrombocytopenia-<1lakh/mm3Thrombocytosis->4.5Lakhs/mm3
Interpretation of ESR
ESR vs CRP
Interpretation of Blood sugars
GLUCOMETER(LESS RELIABLE/EMERGENCIES/HOME USE)
GLUCOSE OXIDASE METHOD
MANUAL/AUTOANALYSER)(LABORATORY/DEPENDABLE/TAKES TIME)
Interpretation of Blood sugar levels
HYPERGLYCAEMIA / DIABETES MELLITUS
HYPOGLYCAEMIA
MILD HYPOGLYCA
EMIA-<70mg/dl
SEVERE HYPOGLYC
AEMIA-<45mg/dl
Causes of Glucose level variations
Hyperglycaemia
Diabetes Mellitus
Drugs(eg Steroids)
IV fluids
Infections
Stress
Pancreatitis
Hypoglycaemia
Starvation
OHAs/Insulin overdose
Alcohol
CKD
Liver diseases
Malignancy
Hypothyrodism
Infections
Interpretation of Renal function tests(RFTs)
Urine Analysis
Blood urea
Serum creatinine
Serum uric acid
GFR(wont be discussed here)
Tubular function test (Wont be discussed here)
Cystatin C (Novel marker,wont be discussed here)
Urine Analysis
Color- Pale yellow Normally, Cloudy appearance suggest infection
Urine Analysis
Urine Analysis
Urine Analysis
Urine Analysis
Urine Analysis
Urine Analysis
Urine Analysis
Urine Analysis
RFTs
RFTs
RFTs
RFTs
RFTs
RFTs
RFTs
Interpreting LFTs
Bilirubin:
• Total Bilirubin
• Direct Bilirubin (conjugated bilirubin)
Serum aminotransferases
• Aspartate aminotransferase (AST/SGOT)
• Alanine aminotransferase (ALT/SGPT)
Total Proteins
Albumin
Globulin
A/G Ratio
Alkaline Phosphatase
Prothrombin time
TOTAL BILIRUBIN(REPORTED IN LFT)
Used to determine liver’s ability to clear endogenous/exogenous substances from the circulation
Derived mainly from hemoglobin (95%)
Continuous production (300 mg daily)
Normal values of “Total” bilirubin = 0.1-1.0 mg/dL
Jaundice usually develops with a bilirubin ≥ 3 mg/dL
SUBTYPES OF BILIRUBIN
DIRECT BILIRUBIN
Reported in LFT
0.0-0.2mg%
Conjugated hyperbilirubinaemia >15% T.Bilirubin
Rarely exceeds >6mg% in the absence of renal dysfunction
Conjugated
Water soluble
Polar
Seen in urine
Elevated with biliary obstruction and hepatocellular disease.
INDIRECT BILIRUBIN
CALCULATED
Total Bilirubin- Conjugated bilirubin
If >85% of total bilirubin-Unconjugated hyperbilirubinemia
Lipid soluble/Water insoluble
Non-polar
Not in urine
Elevated with Gilberts syndrome,hemolysis, hepatic disease
LIVER ENZYMES or AMINOTRANSFERASES
Hepatic enzymes that are usually intracellular, but are released from hepatocytes with hepatocellular injury.
Catalyze -amino group transfers
• aspartate or alanine ketoglutarate
AST/ALT ratio
• Normal is 0.8
• In alcoholic hepatitis, is usually > 2
Liver Enzymes or Aminotransferases
Elevated in nearly all liver diseases (ALT > AST)
Markedly usually in hepatocellular disease
Levels may/may not reflect extent of damage
Do not correlate with eventual outcome
Usually <500 in obstructive jaundice
Exception: acute phase of biliary obstruction by the passage of a gallstone into the common bile duct. In this, the aminotransferases can briefly be in the 1000–2000 IU/L range. However, levels decrease quickly, and the LFT rapidly evolve into typical of cholestasis
Usually parallel each other
AST > ALT with EtOH, fulminant, and pregnancy
AMINOTRANSFERASES
Aspartate aminotransferase (AST/SGOT)
In cytosol and mitochondria
Liver > heart > skeletal muscle > kidneys > brain > pancreas > lungs > WBCs > RBCs
Half-life 17hrs
Alanine aminotransferase (ALT/SGPT)
In cytosol Predominantly
liver More sensitive
and specific than AST
Half-life 47hrs
Liver Enzymes
Acute hepatocellular disordersALT is higher than or equal to the AST.
C/c viral hepatitis and NAFLDAST:ALT ratio is typically <1 (but as cirrhosis develops, this
ratio rises to >1)
Alcoholic liver disease AST:ALT ratio >2:1 . The AST in alcoholic liver disease is rarely >300 IU/L, and the
ALT is often normal. A low level of ALT in the serum is due to an alcohol-
induced deficiency of pyridoxal phosphate
Alkaline Phosphatase
Enzymes that catalyze hydrolysis of large number of organic phosphate esters.
ALP mainly comes from surface of bile duct epithelial cells. Cholestasis enhances synthesis and release of ALP
Since half life is 1week ; ALP rise late in bile obstruction and decrease slowly after resolution
Found in: Liver Bone intestine 3rd trimester placenta Kidney
Alkaline Phosphatase
Increases seen with cell injury or
obstruction
Slight to moderate (1-2x) – usually
hepatocellular
Large increases (3-10x) –
obstruction or cholestasis
Alkaline phosphatase
GAMMA-GLUTAMYL TRANSPEPTIDASE (GGT)
To confirm hepatic source of ALP Elevated ALP of Liver origin: Elevated GGT
Elevated ALP of Bone origin: Normal GGT Normal levels=0-45 IU/L
Non specific as Causes of elevations includeLiver disease » Pancreatic
diseaseAlcohol » Renal diseaseCardiac disease » ObesityRadiotherapy » DiabetesDrugs – GGT is “inducible”
phenobarbital anticoagulants dilantin oral contraceptives acetaminophen tricyclic antidepressants
Usually normal in pregnancy
GAMMA-GLUTAMYL TRANSPEPTIDASE (GGT)
Prothrombin Time (PT)
Normal range PT is:11 to 13.5 seconds (Test)
INR of 0.8 to 1.1
Liver is in charge of the synthesis of many clotting factors :
Factor I (fibrinogen) , II (prothrombin) ,V ,VII , IX , X , XII and XIII
PT measures the rate of conversion of prothrombin to thrombin (requiring factors II, V, VII, and X) and thus reflects a vital synthetic function of the liver
Elevated PT may be reflection of decreased synthetic activity of liver.
Prothrombin Time (PT)
Other causes of prolongation:
congenital deficienciesconsumptive coagulopathies (i.e., DIC)drugs (i.e., warfarin)vitamin K deficiency (i.e., dietary, bile output)
Prothrombin Time (PT)