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Laboratory Interpretation

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พญ.รพีพร โรจน์แสงเรือง …

พญ.รพีพร โรจน์แสงเรือง
โครงการจัดตั้งภาควิชาเวชศาสตร์ฉุกเฉิน
คณะแพทยศาสตร์รพ.รามาธิบดี

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  • 1. Laboratory Interpretation พญ . รพีพร โรจน์แสงเรือง โครงการจัดตั้งภาควิชาเวชศาสตร์ฉุกเฉิน คณะแพทยศาสตร์รพ . รามาธิบดี
  • 2. KIDNEY
  • 3. Creatinine
    • Creatine is synthesized in the liver. It is the chief source of high-energy phosphocreatine for muscle metabolism.
    • It loses water to become creatinine, all of which is excreted.
    • Use for renal function
  • 4. case
    • Male 60 years old came with fatigue BUN=40/Cr=2
    • This is renal failure –renal /prerenal?
  • 5.
    • Old man will lose muscle mass that makes low Cr.
    • It might be prerenal or renal failure. You will ask for U/A to look for sp.Gr.
  • 6. Urine hCG
    • Normal pregnancy -secreted first by trophoblastic cells of conceptus and later by placenta
    • positive as early as 4 days after expected date of menstruation
    • it is >95% reliable by the 10th to the 14th day. Human chorionic gonadotropin (hCG) increases to a peak between the 60th and 70th days then decreases progressively.
  • 7. Urine hCG
    • False-Positive Result
    • -Drugs, e.g., chlorpromazine, phenothiazines
    • -Bacterial contamination
    • -Protein or blood in urine
    • False-Negative Result
    • -Dilute urine
    • -Missed abortion
    • -Dead fetus syndrome
  • 8. Hematuria
    • <3% of normal persons ( ≥3 RBCs/HPF )
    • 18% of persons after very strenuous exercise.
    • The source of microscopic hematuria remains obscure in ~70% of cases after workup .
  • 9. Nonglomerular Hematuria
    • Caused By
    • Trauma
    • Hemoglobinopathies
    • Polycystic disease
    • GU tract tumors, infections
  • 10.  
  • 11. Hematuria in Children
    • Caused By
    • -Glomerular Causes
    • Acute postinfectious GN
    • Membranoproliferative GN
    • IgG-IgA nephropathy (Berger disease)
    • Hereditary nephritis (Alport syndrome)
    • SLE
    • Renal infarction
    • Henoch-Schönlein purpura
    • -Nonglomerular Causes
    • Polycystic kidneys
    • Renal tumors
    • Hydronephrosis
    • GU tract infection, foreign body, calculi, etc.
  • 12. Ketonuria
    • is diagnosed when ketone bodies (acetone, beta-hydroxybutyric acid, acetoacetic acid) appear in urine.
    • Use Screening for ketoacidosis, especially in diabetes mellitus when blood is not immediately available
  • 13. case
    • 30 year-old Female came with kussmual breathing and underlying DM
    • Her BS= 500, Hco3=10,urine ketone-neg
    • What is her diagnosis?
  • 14.
    • DKA
    • Measure serum ketone or urine ketone cannot measure beta-hydroxybutyric acid ( measure esp.acetoacetate /acetone)
    • DKA +lactic acidosis have high beta-hydroxybutyric acid
  • 15. Ketonuria
    • Metabolic conditions (e.g., diabetes mellitus, renal glycosuria)
    • Dietary conditions (e.g., starvation, high-fat diets)
    • Increased metabolic requirements (e.g., hyperthyroidism, fever, pregnancy and lactation)
  • 16. Prerenal azotemia
    • specific gravity >1.030 and
    • Urine osmolality >500 mOsm/kg)
  • 17. Proteinuria
    • Transient(10%)
    • high fever
    • CHF
    • HT
    • Stress exposure to cold, strenuous exercise, seizures.
    • Usually <2 g/d; disappears with recovery from precipitating cause.
  • 18. Proteinuria
    • PERSISTENT
    • Glomerular
    • Idiopathic (e.g., membranoproliferative GN, membranous glomerulopathy)
    • Secondary
      • Infection (e.g., poststreptococcal, hepatitis B, bacterial endocarditis, malaria)
      • Vascular (e.g., renal artery stenosis)
      • Drugs (e.g.NSAIDS, heroine, captopril, penicillamine)
      • Autoimmune (e.g., SLE, RA, dermatomyositis, Henoch-Schönlein purpura, ulcerative colitis)
      • Neoplasia
  • 19. Microalbuminuria
    • Microalbuminuria is defined as persistent proteinuria that is below detection by routine reagent strips but greater than normal.
  • 20. Microalbuminuria
    • patients with DM: microalbuminuria
    • associated with longer duration of diabetes, poorer glycemic control, higher BP, advanced retinopathy and neuropathy, subsequent renal failure , and increased vascular damage and risk for cardiovascular disease.
  • 21. Bence-Jones Proteinuria
    • UseDetection of various gammopathies
    • 80% of tests are true positive-Myeloma (70% )
    • False positive
    • CNT (e.g., RA, SLE, scleroderma)
    • Chronic renal insufficiency
    • Lymphoma /leukemia
    • Metastatic carcinoma of lung, gastrointestinal, or GU tracts
  • 22. Anuria
    • < 100 mL of urine in 24 hours.
    • Caused By
    • Bilateral complete urinary tract obstruction
    • Acute cortical necrosis
    • Necrotizing glomerulonephritis
    • Certain causes of acute tubular necrosis
  • 23. Oliguria
    • is usually defined as excretion of less than 400 mL of urine in 24 hours(in children< 15 to 20 mL/kg/24 h)
    • Caused By
    • Prerenal causes (e.g., CHF, shock)
    • Postrenal causes
    • Renal causes
  • 24. Polyuria
    • urine volume > 2,000 mL / day.
    • Caused By
    • Osmotic diuresis( DM)
    • Polydipsia(DI)
    • Diuretic drugs
    • Chronic renal failure
    • Partial obstruction of urinary tract with impaired urinary concentration function
    • acute tubular necrosis (aminoglycosides)
  • 25. CARDIO
  • 26. Acute rheumatic fever
    • occurring 10 days to 6 weeks following an episode of group A Streptococcus infection.
    • Diagnostic criteria confirmation of preceding group A Streptococcus infection by
    • 1.Positive throat culture
    • 2. Increased serologic titer of antistreptococcal antibodies
  • 27. Acute rheumatic fever
    • Symptom+2 major / 1 major + 2 minor
    • Minor Criteria: High ESR or CRP, prolonged P-R interval, fever, arthralgia
    • Major Criteria: Carditis, arthritis, Sydenham chorea, subcutaneous nodules, erythema marginatum
  • 28.
    • To determine clinical activity—follow ESR, CRP, and WBC.
    • Return to normal should be seen in 6 to 12 weeks in 80% to 90% of patients
    • it may take ≤6 months
  • 29. Cor Pulmonale
    • polycythemia
    • Increased blood CO2
    • the primary lung disease (e.g., chronic bronchitis and emphysema
  • 30. Blood lipid tests
    • should not be performed during stress or acute illness (2 to 3 months after illness )
    • after a 12- to 13-hour fast
  • 31. Myocardial Infarction
    • Characteristics of Serum Markers for Myocardial Damage
    • Early appearance : Myoglobin, CK isoforms
    • High specificity : cTnI, cTnT, CK-MB, CK isoforms
    • Wide diagnostic window : cTnT, cTnI, LD
    • Risk stratification : cTnT, cTnI, CK-MB
    • Predicts reperfusion : Myoglobin, cTnI, cTnT, CK isoforms
    • Indicates reinfarction after 2–4 d : CK-MB
  • 32. cTn
    • cTn is as sensitive as CK-MB during the first 48 hours after AMI
    • Specificity close to 100%. High sensitivity for 6 days.
    • cTnT may remain increased for ≤14 days.
  • 33. cTn
    • cTnI is not increased by skeletal muscle injury, making it more highly specific for myocardial injury.
    • cTnI/ cTnT may be detected in 10% to 30% of patients with CRF
  • 34. CPK-MB
    • Use in
    • Detect reinfarction or extension of MI after 72 hours.
    • Document reperfusion after thrombolytic therapy.
  • 35.
    • CK-MB usually is evident at 4 to 8 hours, peaks at 15 to 24 hours
  • 36. Serum Myoglobin
    • is an oxygen-carrying respiratory protein found only in skeletal and cardiac muscle.
    • Earliest marker for AMI.
    • Increased 1 to 3 hours in >85% of AMI patients
    • peaks 8 to 12 hours
    • becomes normal in about 24 to 36 hours or less;
  • 37. B-type Natriuretic Peptide
    • hormone secreted by myocytes in the ventricles in response to pressure overload/myocyte stretch
    • use: BNP / N-terminal (NT) proBNP.
    • Use in
    • - screening and diagnosis of CHF
    • -Prognostic tool for classes III and IV
    • -Diagnosis of left ventricular dysfunction
  • 38. B-type Natriuretic Peptide
    • cutoff values :
    • BNP: 80 to 100 pg/mL
    • NT-proBNP: 125 pg/mL for age <75
    • Reading <100 pg/mL rules out CHF as cause of dyspnea.
    • Reading >400 pg/mL indicates 95% likelihood of CHF
  • 39. B-type Natriuretic Peptide
    • Increase in BNP in right heart failure is less than in left ventricular dysfunction
    • BNP and NT-proBNP can be increased in renal failure, especially if dialysis is needed
  • 40. Secondary hypertension
    • causes <10% of cases of hypertension.
    • Many causes for secondary HT=?
  • 41. Secondary hypertension
    • Endocrine diseases
      • Adrenal, e.g., pheochromocytoma, Cushing syndrome
      • Pituitary disease, e.g., acromegaly
      • Hyperthyroidism, hyperparathyroidism, etc.
    • Renal diseases
      • renal artery stenosis, nephrosclerosis, embolism
      • Parenchymal, e.g., glomerulonephritis, polycystic kidneys
    • Other, e.g., toxemia of pregnancy, polycythemia, acute porphyria
    • Drugs, e.g., oral contraceptives, tricyclic antidepressants, licorice
    • Toxic substances, e.g., poisoning by lead or cadmium
  • 42. HT+ Hypo K
    • Ought to think about many diseases?
  • 43. HT+ Hypo K
    • Primary aldosteronism
    • Pseudoaldosteronism (caused by excessive ingestion of licorice)
    • Secondary aldosteronism, e.g., malignant hypertension
    • Hypokalemia caused by diuretic administration
    • Potassium loss caused by renal disease
    • Cushing syndrome
  • 44. Infective endocarditis (IE)
    • 2 major criteria
    • 1 major plus 3 minor criteria
    • 5 minor criteria
    • pathologic findings (vegetation or intracardiac abscess confirmed histologically showing active endocarditis).
  • 45. Major Criteria
    • Typical organism in ≥2 blood cultures in absence of primary focus, or persistently positive blood cultures drawn >1 hour apart
    • Involvement of endocardium by echocardiogram or valve regurgitation
    • Positive serology for Coxiella burnetii (IgG >1:800)
    • Bacterial or fungal DNA in blood or valve (including Bartonella sp., Tropheryma whipplei, other new or unusual organisms)
    • S. aureus bacteremia, even if nosocomial or removable source of infection is present
    • Positive echocardiogram (e.g., oscillating intracardiac mass)
  • 46. Typical pathogen in IE
    • Streptococcus viridans [~50% of cases]
    • S. bovis
    • Staphylococcus aureus
    • HACEK [Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella]
  • 47. Minor Criteria
    • Risk factors: predisposing heart condition / IV drug abuse
    • Fever >38°C (100.4°F)
    • Vascular phenomena: septic pulmonary infarcts, major arterial emboli, Janeway lesions
    • Immunologic phenomena: Osler nodes , Roth spots
    • Microbiologic evidence: positive blood culture other than major criteria or positive serologic findings (Bartonella sp. or Chlamydia sp.)
    • Clinical: newly diagnosed clubbing or splinter hemorrhages , microscopic hematuria
    • Biochemical: CRP >100 mg/L or ESR >30 mm/h
  • 48. Risk Factors
    • Preexisting valve disease / congenital heart diseases
    • Nosocomial: most are caused by enterococci and staphylococci. Case fatality >50%:
      • IV lines; S. aureus in patients with central venous catheters, parenteral lines for feeding or chemotherapy
      • Hemodialysis patients: >50% are caused by S. aureus
    • S. bovis in patients with colon cancer causes 20% of cases
    • Enterococcus faecalis in patients: genitourinary procedures, pelvic infections, prostate disease
    • Blood culture is positive in 80% to 90% of patients:
  • 49.
    • Proper blood cultures require adequate volume of blood, at least five cultures taken during a period of several days with temperature 101°F or higher
    • Beware of negative culture due to recent antibiotic therapy.
    • based on ≥2 cultures that are positive for the same organism.
  • 50. case
    • Male 60 years old came with fever
    • His H/C- strept. Bovis
    • How to treat?
  • 51.
    • Treat with antibiotic
    • Colonoscope finds CA colon
  • 52. Prosthetic Heart Valves
    • Early - caused by S. epidermidis, S. aureus; also gram-negative bacteria, fungi
    • Late (>60 days postoperatively). Usually caused by streptococci., S. epidermidis
    • Surgery is indicated if blood culture is still positive after 5 days of appropriate antimicrobial therapy or recurrent infection
  • 53. Syphilitic Aortitis
    • Syphilitic aortitis is an obliterative endarteritis of vasa vasorum of thoracic aorta that can lead to aneurysm formation.
    • Aortitis is the most common expression of late syphilis
    • A positive treponemal test is seen in ~90% of cases.
  • 54. Behçet Syndrome
    • is a systemic vasculitis -a triad of recurrent aphthous ulcers of mouth and genitalia, and relapsing panuveitis.
    • No definitive laboratory tests are available.
  • 55. Giant cell arteritis (GCA)
    • is a systemic panarteritis of the large and medium arteries, especially the carotid arteries.
    • affects the extracranial > the intracranial arteries.
    • Biopsy of the involved segment of temporal artery is diagnostic
  • 56.
    • The classic triad of increased ESR (≥50 mm/h),anemia, and increased serum ALP is strongly suggestive of GCA
    • Laboratory findings reflecting specific organ involvement (Kidney ,CNS,Heart)
  • 57. Henoch-Schönlein Purpura
    • is a hypersensitivity systemic vasculitis of the small vessels with IgA deposition.
    • abdominal symptoms are predominant
    • Diagnosis is made clinically
    • there are no pathognomonic laboratory findings. Coagulation tests are normal.
    • Renal or skin biopsy supports the diagnosis; it will show focal segmental necrotizing GN that with IgA and C3 deposition.
  • 58. Kawasaki Syndrome (Mucocutaneous Lymph Node Syndrome)
    • is a variant of childhood polyarteritis of unknown etiology, with a high incidence of coronary artery complications.
    • Diagnosis is confirmed by histologic examination of the coronary artery (same as polyarteritis nodosa)+Laboratory changes due to AMI.
  • 59. Takayasu syndrome
    • is the term for granulomatous arteritis of the aorta.
    • Diagnosis is established by characteristic arteriographic changes or histologic examination
  • 60. Thromboangiitis Obliterans (Buerger Disease)
    • is the vascular inflammation and occlusion of medium and small arteries and veins of limbs; it is related to smoking.
    • Histology shows characteristic inflammatory and proliferative lesions
  • 61. Wegener Granulomatosis (WG)
    • is a rare autoimmune systemic necrotizing or granulomatous vasculitis most often affecting the respiratory tract and kidneys.
    • c-ANCA is highly specific (>90%) for active WG.
  • 62. GI
  • 63. Diarrhea -PMN
    • Shigellosis,Salmonellosis,Campylobacter,
    • Rotavirus,Invasive Escherichia coli colitis
    • Ulcerative colitis
    • Pseudomembranous colitis
  • 64. Diarrhea –no cell
    • Cholera
    • Noninvasive E. coli diarrhea
    • Other bacterial toxins (e.g., Staphylococcus, Clostridium perfringens)
    • Viral diarrheas
    • Parasitic infestations (e.g., G. lamblia, Entamoeba histolytica, Dientamoeba fragilis)
    • Drug related
  • 65. Plummer-Vinson Syndrome
    • an iron-deficiency anemia associated with dysphagia, atrophic gastritis, glossitis, etc
    • increased risk of cancer of the esophagus
  • 66. Pseudomembranous colitis
    • is an antibiotic-related diarrhea and colitis caused by C. difficile.
    • Tissue culture assay is gold standard
    • Character of stool-?
  • 67. Enterocolitis, Necrotizing, in Infancy
    • a syndrome of acute intestinal necrosis of unknown etiology; it is especially associated with prematurity and exchange transfusions.
    • No specific laboratory tests are available.
    • Persistent metabolic acidosis, severe hypoNa, and DIC are a common triad in infants.
  • 68. Infarction of the Intestine
    • Hematemesis, hematochezia, or melena are present in ~15% and occult blood in <50% of cases.
    • Caused by
    • Primary (idiopathic)
    • Secondary (~75% of cases) to:
    • Emboli (SBE), nonbacterial valve vegetations, left atrium or ventricle, atherosclerotic vascular disease,Venous thrombosis
  • 69. Ascites
    • blood-AF albumin gradient >1.1: portal HT
    • • neutrophils count >250/µL is presumptive of bacterial peritonitis.
    • Gram stain shows few bacteria in SBP Culture sensitivity = 50% for SBP and ~80% for secondary peritonitis
    • • TB acid-fast stain sensitivity = 20% to 30% and TB culture sensitivity = 50% to 70%.
  • 70. Chylous Ascites
    • Triglyceride is 2-8 × serum level.
    • Due to
    • lymphatic obstruction (lymphoma or CA)
    • inflammation or obstruction of small intestine trauma to chest or abdomen,
    • filariasis;
    • congenital lymphatic defects in pediatric
  • 71. Abdominal Trauma
    • Criteria to diagnose penetrating abdominal wounds by peritoneal lavage10,000 mL of normal saline 3 to 18 hours after injury :
    • >10,000 RBC/µL (>5,000 RBC/µL for gunshot wounds)
    • Bacteria, fecal or vegetable matter on Gram stain or bile
  • 72. Occult Bleeding
    • guaiac -detect blood losses of ~20 mL/d.
    • Use of fecal sample obtained by digital rectal exam is not recommended
    • Stools may appear grossly normal with GI bleeding of 100 mL/d.
    • Consistent melena requires 150 to 200 mL blood in the stomach
    • False positive in FBC, animal blood food
  • 73. RESP.
  • 74. Croup or laryngotracheitis
    • inflammation of the upper airway below the glottis.
    • Caused by
    • Group B Haemophilus influenzae causes >90% of cases of epiglottitis; other bacteria include β-hemolytic streptococci and pneumococci.
  • 75. Pneumonia
    • Prussian blue–nuclear red stain strongly positive indicates severe alveolar hemorrhage
    • Pap smear- intranuclear inclusions of herpes or CMV
    • Giemsa,GMS of sputum - PCP
  • 76. Pleural fluid
    • Light criteria-exudate/transudate
    • 1.LDH in fluid > 2/3 normal serum LDH
    • 2.Protein fluid/serum> 0.5
    • 3.LDH fluid/serum> 0.6
    • 4.Serum alb-fluid alb <1.2
  • 77. Pleural fluid
    • Nonpurulent fluid with positive Gram stain, positive blood culture, or low pH suggests that effusion will become or behave like empyema
    • Streptococcus pneumoniae causes parapneumonic effusions in 50% of cases, especially with positive blood culture
  • 78. case
    • Male 25 years old came with dyspnea
    • CXR-left pleural effusion
    • Pleural tapping-WBC>50,000, high neutrophils
    • Need ICD?
  • 79.
    • No ICD
    • Indication for ICD
    • 1.PH< 7
    • 2.SUGAR<40
    • 3.Frank pus
    • 4.Gram stain /Culture +
  • 80.
    • pH <7.0 and glucose <40 mg/dL indicate need for ICD without grossly purulent fluid.
    • pH of 7.0–7.2 is a questionable indication and should be repeated in 24 h, but ICD is favored if pleural fluid LD >1,000 IU/L.
    • ICD is also indicated if there is grossly purulent fluid or positive Gram stain or culture.
  • 81. hemothorax
    • hematocrit (Hct) >50% of peripheral Hct indicates a hemothorax.
    • Cytology establishes the diagnosis in approximately 50% of patients.
    • Cytology plus biopsy is diagnostic in about 90% of cases
  • 82. Exudative effusion
    • Caused by
    • Pneumonia, malignancy, pulmonary embolism, and gastrointestinal conditions (especially pancreatitis and abdominal surgery) cause 90% of all exudates
  • 83. Pleural effusion
    • Typically left-sided: Ruptured esophagus, acute pancreatitis, RA
    • Typically right-sided or bilateral: Congestive heart failure (CHF)
    • Typically right-sided: Rupture of amebic liver abscess.
  • 84. Chylous
    • Chylous (milky) is usually due to trauma or obstruction of duct
    • PF triglycerides (TG) >110 mg/dL or TG PF:serum ratio >2 occurs only in chylous effusion
  • 85. pseudochylous effusions
    • Chylomicrons ≤50 mg/dL with cholesterol >250 mg/dL.
  • 86. Amylase
    • Increased PF:serum ratio >1.0
    • Acute pancreatitis—may be normal early with increase over time
    • Also perforated esophageal rupture, peptic ulcer, necrosis of small intestine
  • 87. TB pleura
    • Large mesothelial cells >5% are said to rule out TB
    • Acid-fast smears are positive in only <20% of TB pleurisy
    • Sensitivity >50% in TB. Cultures from chest tubes
    • culture combined with histologic examination establishes the diagnosis in 95% of cases
    • Adenosine deaminase >70 IU/L
  • 88. Malignancy effusion
    • Cytology is positive in 60% of malignancies on first tap, 80% by third tap. Is more sensitive than needle biopsy
    • Combined cytology and pleural biopsy give positive results in 90%.
  • 89. Sputum exam
    • Optimum specimen of sputum shows >25 PMNs and ≤5 squamous epithelial cells/LPF
    • Sensitivity of sputum culture is estimated at 25% to 50%.
  • 90. Carcinoma, Bronchogenic
    • Cytologic examination of sputum for malignant cells
    • -positive in 40% of patients on first sample
    • -70% with three samples
    • -85% with five samples.
    • False-positive tests are <1%.
  • 91. CA lung
    • Classified as:
    • Non-small cell lung carcinoma (NSCLC) in 70% to 75% of cases
    • Squamous cell carcinoma (25%–30%)
    • Adenocarcinoma (30%–35%)
    • Large cell carcinoma (10%–15%)
    • Small cell lung carcinoma (SCLC) in 20% to 25% of cases
    • Combined pattern in 5% to 10% of cases
  • 92.
    • LE cells makes the diagnosis of SLE
    • CHF is typically bilateral; ≤20% are right-sided and ≤9% are left-sided
  • 93. Plasma D-dimer
    • is a fibrin product generated by action of plasmin on cross-linked fibrin molecules indicating that a clot has formed
    • At cutoff level of 500 µg/L
  • 94. Hepatobiliary
  • 95. Total Serum Bilirubin
    • Must exceed 2.5 mg/dL to produce clinical jaundice
  • 96. Serum Bilirubin (Conjugated:total)
    • <20% conjugated
      • Constitutional (e.g., Gilbert disease, Crigler-Najjar syndrome)
      • Hemolytic states
    • 20% to 40% conjugated
      • Favors hepatocellular disease rather than extrahepatic obstruction
      • Disorders of bilirubin metabolism (e.g., Dubin-Johnson, Rotor syndromes)
    • 40% to 60% conjugated: Occurs in either hepatocellular or extrahepatic type
    • >50% conjugated: Favors extrahepatic obstruction rather than hepatocellular disease
  • 97. AST
    • Half-life of AST is 18 hours
    • half-life of ALT is 48 hours.
    • Thus, in early acute hepatitis, AST is usually higher initially, but by 48 hours, ALT is usually higher.
  • 98. ALP
    • Increased ALP in liver diseases (due to increased synthesis from proliferating bile duct epithelium) is the best indicator of biliary obstruction
    • High values (>5× normal) favor obstruction
    • Isolated increase of GGT is a sensitive screening and monitoring test for alcoholism
  • 99.
    • In cirrhosis with ascites, the kidney retains increased sodium and excessive water, causing dilutional hyponatremia
    • Blood ammonia is increased in liver coma and cirrhosis and with portacaval shunting of blood.
  • 100.
    • WBC is usually normal with active cirrhosis; increased (<50,000/µL) with massive necrosis, hemorrhage, etc.; decreased with hypersplenism.
  • 101. Hep. encephalopathy
    • Blood ammonia is increased in 90% of patients but does not reflect the degree of coma. Normal level in comatose patient suggests another cause of coma. Not reliable for diagnosis but may be useful to follow individual
  • 102. SBP
    • Spontaneous bacterial peritonitis—in 10% to 30% of cirrhosis cases with ascites.
    • 70% have positive blood culture; usually single organism, especially E. coli, pneumococcus, Klebsiella.
    • ≥ 250 PMNs/µL is diagnostic.
  • 103.
    • AST:ALT ratio >1 associated with AST <300 U/L will identify 90% of patients with alcoholic liver disease; is particularly useful for differentiation from viral hepatitis, in which increase of AST and ALT are about the same.
    • Anemia in >50% of patients may be macrocytic (folic acid or vitamin B12 deficiency), microcytic (iron deficiency), mixed, or hemolytic.
    • In acute alcoholic hepatitis, GGT level is usually higher than AST level. GGT is often abnormal in alcoholics even with normal liver histology. Is more useful as index of occult alcoholism
  • 104. hepatitis
    • Hepatitis, Chronic ActiveProgressive hepatitis >6 months duration of unknown etiology affecting patients of all ages possibly due to an external agent Due To
    • Viruses
    • HBV (with or without HDV)
    • HCV (with or without HGV)
    • CMV, others
  • 105. hepatitis
    • Metabolic
    • Wilson disease
    • Alpha1-antitrypsin deficiency
    • Hemochromatosis
    • Primary biliary cirrhosis
    • Sclerosing cholangitis
  • 106. hepatitis
    • Drugs (e.g., methyldopa, nitrofurantoin, isonizid, oxyphenacetin) and chemicals
    • Nonalcoholic fatty liver
    • Alcoholic hepatitis
    • Autoimmune causes
  • 107. Acute pancreatitis
    • Serum Lipase
    • Increases within 3 to 6 hours with peak at 24 hours and usually returns to normal over a period of 8 to 14 days.
    • Is superior to amylase; increases to a greater extent and may remain elevated for up to 14 days after amylase returns to normal.
  • 108. acute pancreatitis
    • -In patients with signs of acute pancreatitis, pancreatitis is highly likely (clinical specificity = 85%) when lipase ≥5× URL, if values change significantly with time, and if amylase and lipase changes are concordant.
    • -Lipase should always be determined whenever amylase is determined. New methodology improves clinical utility.
  • 109.
    • It has been suggested that a lipase:amylase ratio >3 (and especially >5) indicates alcoholic rather than nonalcoholic pancreatitis).
  • 110. predisposing conditions of pancreatitis
    • Alcohol abuse accounts ~36% of cases.
    • Biliary tract disease accounts 17% of cases.
    • Idiopathic accounts >36% of cases.
    • Infections (especially viral such as mumps and coxsackie, CMV, AIDS)
    • Trauma and postoperative accounts >8% of cases
    • Drugs (e.g., steroids, thiazides) >5% of cases.
    • Hypertriglyceridemia (Hyperlipidemia—Types V, I, IV) 7% of cases
    • Hypercalcemia
    • Tumors (pancreas, ampulla)
    • Anatomic abnormalities of ampullary region causing obstruction
    • Hereditary
    • Renal failure; renal transplantation
  • 111. Prognostic laboratory findings
    • On admission
    • WBC >16,000/µL
    • Blood glucose >200 mg/dL
    • Serum LD >350 U/L
    • Serum AST >250 units/L
    • Age >55 years
    • Within 48 hours
    • >10% decrease in HCT
    • Serum calcium <8.0 mg/dL
    • Decrease in Hct >10 points
    • Increase in BUN >5 mg/dL
    • Arterial pO2 <60 mmHg
    • Metabolic acidosis with base deficit >4 mEq/L
  • 112. prognosis
    • Degree of amylase elevation has no prognostic significance
    • CT scan, MRI, ultrasound are useful for confirming diagnosis or identifying causes or other conditions
  • 113. CNS
  • 114. CSF
    • CSF -WBC may be corrected for presence of blood (e.g., traumatic tap, subarachnoid hemorrhage) by subtracting 1 WBC for each 700 RBCs/µL counted in CSF if the CBC is normal.
  • 115. Neutrophilic leukocytes in CSF
    • are found in:
    • Bacteria (e.g., Nocardia, Actinomyces, Arachnia, Brucella)
    • Fungal infections (Blastomyces, Coccidioides, Candida, Aspergillus, Zygomycetes, Cladosporium, Allescheria)
    • Chemical meningitis
    • Other conditions (e.g., SLE)
  • 116. Lymphocytic cells in CSF
    • are found in:
    • Bacterial infections (e.g., Treponema pallidum, Leptospira,, Borrelia burgdorferi [Lyme disease], M. tuberculosis)
    • Fungal infections (e.g., Cryptococcus neoformans, Candida species, Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitides)
    • Parasitic diseases (e.g., toxoplasmosis, cysticercosis)
    • Viral infections (e.g., mumps, lymphocytic choriomeningitis). Atypical lymphocytes may be seen in EBV infection and less often in CMV or HSV infection.
    • Parameningeal disorders (e.g., brain abscess)
    • Noninfectious disorders (e.g., neoplasms, sarcoidosis, multiple sclerosis, granulomatous arteritis)
  • 117. Eosinophils In CSF
    • be found in:
    • Lymphoma
    • Helminth infection (e.g., angiostrongyliasis, cysticercosis)
    • Rarely, other infections (e.g., TB, syphilis, Rocky Mountain spotted fever, coccidioidomycosis)
    • Eo>5% may indicate malfunction or infection of a ventriculoperitoneal shunt
  • 118. Multiple Sclerosis (MS)
    • CSF changes are found in >90% of MS patients. Oligoclonal IgG bands or elevated IgG index are the 2 CSF findings recognized as positive.
  • 119. musculoskeletal
  • 120. Serum Enzymes in Diseases of Muscle
    • Creatine kinase (CK) is the test of choice. It is more specific and sensitive than AST and LD and more discriminating than aldolase (ALD) but AST is more significantly associated with inflammatory myopathy and more useful in these cases
    • Increased In
    • Polymyositis
    • Muscular dystrophy
    • Myotonic dystrophy
    • Some metabolic disorders
    • Malignant hyperthermia
    • Prolonged exercise; peak 24 hours after extreme exercise (e.g., marathon); smaller increases in well-conditioned athletes
    • Wilms tumors with rhabdomyomatous features (CK-MB may also be increased
  • 121. Hyperthyroidism
      • Normal serum M.enzyme levels
      • Increased urine creatine; decreased creatine tolerance
      • Normal muscle biopsy findings
      • Causes some cases of hypokalemic periodic paralysis
  • 122. Malignant Hyperthermia
    • Rare autosomal dominant hypermetabolic syndrome
    • causing abnormally increased release of calcium from membrane of sarcoplasmic reticulum
    • triggered by various inhalational [e.g., ether] and local anesthetic agents, muscle relaxants [e.g., succinylcholine, tubocurarine]
    • causing hyperthermia, muscle rigidity, and 70% fatality
    • Combined metabolic and respiratory acidosis is the most consistent abnormality and is diagnostic in the presence of muscle rigidity or rising temperature. pH is often <7.2, BE >-10, hypoxia, and arterial pCO2 of 70 to 120 torr. Immediate arterial blood gas analysis should be performed.
  • 123. Myopathy Associated with Alcoholism
    • Acute (necrotizing)
    • Increased serum CK, AST, and other enzymes.
    • Serum CK increased in 80% of patients; rises in 1 to 2 days; reaches peak in 4 to 5 days; lasts ~2 weeks.
    • Gross myoglobinuria
    • Acute renal failure
  • 124. Myopathy Associated with Alcoholism
    • Chronic :
    • Increased serum CK in 60% of patients to average of 2× ULN
    • Increased AST and other enzymes due to liver as well as muscle changes
    • Increased urine creatine
    • Diminished ability to increase blood lactic acid with ischemic exercise
    • Abnormalities on muscle biopsy (support the diagnosis)
    • Myoglobinuria
  • 125. Infective Arthritis
    • Bacterial
      • In purulent arthritis, organism is recovered from joint in 90% of patients and from blood in 50% of patients. Most often due to S. aureus (60%) and Streptococcus species.
      • Gram stain is positive in ~50% of patients; it is particularly useful for establishing diagnosis promptly and in cases in which cultures are negative.
      • Culture may be negative because of prior administration of antibiotics.
      • In children, most common organisms are H. influenzae type b, S. aureus, various streptococci, and gram-negative bacilli.
      • In young adults, >50% of cases are due to Neisseria gonorrhoeae; rest are due to S. aureus, streptococci, or gram-negative bacilli.
  • 126. TB arthritis
    • Gram stain and bacterial cultures are negative
    • but acid-fast stain, culture, and biopsy of synovia confirm the diagnosis
  • 127. Myasthenia Gravis (MG)
    • Acetylcholine Receptor (AChR) Binding Antibodies is the standard assay and should be ordered first:
      • Negative in ≤34% of patients with MG
      • Negative ≤50% of patients with ocular MG
      • May be negative in first 6–12 months
  • 128. Crystalline ArthropathyChondrocalcinosis (“Pseudogout”)
    • Inflammatory mono- or polyarticular arthritis due to deposition of calcium pyrophosphate dehydrate crystals in joints
    • Joint fluid contains crystals identified as calcium pyrophosphate dehydrate, inside and outside of WBCs, and macrophages that are differentiated from urate crystals under polarized light, which distinguishes them from gout.
    • Crystals may also be identified by other means (e.g., chemical, x-ray diffraction).
  • 129. Gout
    • Group of disorders of purine metabolism characterized by monosodium urate crystal deposits in joints and soft tissues
    • episodes of acute inflammatory arthritis [response to crystal deposits], and hyperuricemia.
    • Most uric acid is synthesized in liver and intestinal mucosa.
    • Two thirds excreted by kidney; one third excreted by bowel.
  • 130. Gout
    • Primary (i.e., inborn) (30% of patients)
    • -Idiopathic
    • -Increased purine biosynthesis (Lesch-Nyhan syndrome)
    • Secondary (70% of patients)
    • 1. Overproduction (10% of secondary cases); overexcreters: >750 to 1,000 mg/day of uric acid
      • Neoplastic and hemolytic conditions
      • 2.Increased breakdown of adenosine triphosphate
      • Glycogen storage diseases (I, III, V, VII)
      • Alcohol ingestion
      • Myocardial infarction
    • 3. Decreased renal function (90% of secondary cases); underexcreters: <700 mg/day of uric acid
  • 131. Gout
    • Diagnostic Criteria:
    • -Presence of crystals of monosodium urate from tophi or joint fluid viewed microscopically under polarized light
    • -strongly negative birefringent needle-shaped crystals both inside and outside PMNs or macrophages
    • -differentiates it from pseudogout.
    • (Found in synovial fluid in 75% of patients between attacks.)
  • 132. hemato
  • 133. Macrocytic anemias
    • Macrocytic anemias (MCV >95 fL and often >110 fL; MCHC >30 g/dL)
      • Megaloblastic anemias
      • PA (vitamin B12 or folate deficiency)
      • Sprue (e.g., steatorrhea, celiac disease, intestinal resection or fistula)
      • Macrocytic anemia of pregnancy
      • Alcoholism
      • Liver disease
      • Anemia of hypothyroidism
      • Carcinoma of stomach, following total gastrectomy
      • Drugs:
          • Oral contraceptives
          • Anticonvulsants (e.g., phenytoin, primidone, phenobarbital)
          • Antitumor agents (e.g., methotrexate, hydroxyurea, cyclophosphamide)
      • Antimicrobials (e.g., sulfamethoxazole, sulfasalazine, trimethoprim, zidovu-dine, pyrimethamine
  • 134. Normocytic anemias
    • Normocytic anemias (MCV = 80–94 fL; MCHC >30 g/dL)
    • Following acute hemorrhage
    • Some hemolytic anemias
    • Some hemoglobinopathies
    • Anemias due to inadequate blood formation
  • 135. case
    • 50 years old male came with pale
    • BP นั่ง = 120/70, นอน 130/80
    • Hct=25, MCV=80
    • What is the cause of anemia?
  • 136. Answer UGIH
  • 137. Microcytic anemias
    • Microcytic anemias (MCV <80 fL; MCHC <30 g/dL)
    • Usually hypochromic
      • Iron-deficiency anemia, e.g.,
        • Inadequate intake
        • Poor absorption
        • Excessive iron requirements
        • Chronic blood loss
      • Pyridoxine-responsive anemia
      • Thalassemia
      • Lead poisoning
      • Anemia of chronic diseases
      • Disorders of porphyrin synthesis
  • 138. summary
    • Kidney
    • Cardio
    • GI
    • Respiration
    • Hepatobiliary
    • CNS
    • musculoskeletal
    • Hemato
  • 139. สวัสดี
  • 140. Ferritin
    • Ferritin is an acute-phase reactant and thus is increased in many patients with:
    • various acute and chronic liver diseases
    • alcoholism (declines during abstinence)
    • malignancies (e.g., leukemia, Hodgkin disease)
    • infection and inflammation
    • hyperthyroidism
    • Serum ferritin may not be decreased when iron deficiency coexists with these conditions; in such cases, bone marrow stain for iron may be the only way to detect the iron deficiency.
  • 141. Iron overload
    • Iron overload (e.g., hemosiderosis, idiopathic hemochromatosis).
    • Can be used to monitor therapeutic removal of excess storage iron. Transferrin saturation is more sensitive to detect early iron overload in hemochromatosis
    • serum ferritin is used to confirm diagnosis and as indication to proceed with liver biopsy.
    • Ratio of serum ferritin (in ng/mL) to alanine aminotransferase (ALT) (in IU/L) >10 in iron-overloaded thalassemic patients but averages ≤2 in viral hepatitis; ratio decreases with successful iron chelation therapy.
  • 142. TIBC
    • Iron-Binding Capacity, Total SerumTIBC (in µmol/L) is obtained by the following equation: transferrin (mg/L) × 0.025.
    • Unsaturated iron-binding capacity = TIBC minus serum iron (µg/dL).
    • Use in
    • 1.Differential diagnosis of anemias
    • 2.Should always be performed whenever serum iron is done to calculate percent saturation (see Fig 11-2 ) for diagnosis of iron deficiency
    • 3.Screening for iron overload
    • Increased In
    • -Iron deficiency
    • -Acute and chronic blood loss
    • -Acute liver damage
    • -Late pregnancy
    • Decreased In
    • -Hemochromatosis
    • -Cirrhosis of the liver
    • -Thalassemia
    • -Anemias of infection and chronic diseases (e.g., uremia, RA, some neoplasms
  • 143. SerumTransferrin
    • Transferrin, transports circulating Fe3 molecules.
    • Normally only about 1/3 of iron-binding sites are occupied; the remainder is called unsaturated iron-binding capacity.
    • Increased In
    • -Iron-deficiency anemia; is inversely proportional to iron stores
    • -Pregnancy, estrogen therapy, hyperestrogenism
    • Decreased In
    • -Hypochromic microcytic anemia of chronic disease
    • -Acute inflammation
    • -Protein deficiency or loss (e.g., burns, chronic infections, chronic diseases [e.g., various liver and kidney diseases, neoplasms]), nephrosis, malnutrition)
    • -Genetic deficiency
  • 144. Transferrin Saturation
    • Serum transferrin saturation is obtained by serum iron / TIBC
    • normal 20% to 50%.
    • Use in Differential diagnosis of anemias/ Screening for hereditary hemochromatosis
    • Increased In
    • -Hemochromatosis
    • -Hemosiderosis
    • -Thalassemia
    • -Birth control pills (≤75%)
    • -Ingestion of iron (≤100%)
    • -Iron dextran administration causes increase for several weeks (may be >100%)