2. Laboratory Medicine (Hematology) Flashcards
Why lab medicine is important for us?
C.C.,PMHx,HPI,ROS(Review of Symptoms) ▪ Examination § \_\_\_\_ exam § Imaging studies § \_\_\_\_ tests ▪ Diagnosis ▪ Treatment/management
Extraoral and intramural examination
• how many think that can detect ____ by intra-oral exam - yes you can. Very important but people
don’t. So she hopes her lecture can help us remember in the future
Imaging studies: (goes on tangent about dean’s lecture about caries - not using explorer)
• not taking X-ray to shoot in the dark. When you do an examination on patient, already must have
some ____ in your head, then to confirm the condition you will take images
Same thing with lab tests - not just learning a bunch of the tests - learn them so have an idea what you are testing. Don’t want to overcast
Then come up with diagnosis based on your information
And then treat/manage the patient
extra/intra-oral
lab
anemia
Ddx
Laboratory tests
▪ Approximately 5 billion tests per year in U.S.
▪ 15% increase yearly
▪ No demonstrated ____ in patient care
with ever-increasing laboratory testing
▪ ‘____’ is a significant problem in health care
As she said there are so many laboratory tests. And they are increasing10-15%.
She is getting all this tests from hospital every single day - so we are going to introduce new lab tests and what is criteria/indication. Each has its own code/charging
• Dentists and even physicians are not so familiar about which one we should ____
◦ How we should ____ the order
Over-testing - just remember that if you see any lesion, you can’t just order bunch of blood work to root out any rheumatoid disease (that’s the common things)
• Everybody thinks that if you see an abnormal lesion, that maybe it’s a rheumatoid disease
◦ May be true but you need to know which test you should be ordering
improvement
over-testing
order
interpret
Treating medically compromised patients
▪ Diabetes ▪ Bleeding disorders ▪ Recent MI ▪ Renal failure ▪ HIV ▪ Oral cancer ▪ Pt on medications such as antiplatelet agents or anticoagulants, etc.
Penn is a metabolically complex clinic of oral medicine. See patients with diabetes, bleeding disorders
• Recent MI = myocardial infraction or heart attack
‣ “Recent” nowadays means within ____ month, 6 months is considered a past MI Just reads renal failure, HIV, and oral cancer
Last one - everyone is nervous if patient is on plavix, warfarin, etc.
1
Challenges in the dental clinics
▪ When/how to request medical consultation
▪ How to interpret the response from other health care professionals
▪ How to modify the treatment accordingly
What is your concern as a provider?
So what is your concern usually to treat patient with a medical condition? Why would you be nervous about medically compromised patient care?
• Don’t want to exacerbate the condition
◦ What type of condition can be exacerbated by dental tx? ‣ Inflammatory condition, diabetes
• Diabetes is troubling b/c of wound healing
• So delayed ____ is one major concern
• ____ is another
• ____
So the three major things you worry about - infection, delayed healing, and bleeding after surgery But the biggest one to be honest from our side = ____
• You’re a dentist and your treat patients regularly - and if you miss tongue cancer - this is a big failure
healing
bleeding
infection
misdiagnosed
Top left: see gingival swelling, enlarged gingiva, inflamed (red color)
• What could be potential condition of patient - ____, pregnancy, diabetes, medication
◦ Diabetes causes swelling b/c more susceptible to infections
◦ Medication induced gingival enlargement - ____, calcium channel blocker,
____ (anticonvulsant)
• This picture is actually a leukemia patient
Top right: see leukoplakia of lateral tongue
◦ ____ = white patch, can’t be wiped off
• Is this picture homogenous or not? It is pretty ____ white (not much variation)
• What can be the condition of this patient?
◦ EBV, dysplasia, ____
‣ Oral hairy leukoplakia is very common for HIV patient
• This was a patient with HIV. So #1 want to check if patient has HIV - need blood work
Bottom left: see abnormal tongue - entire dorsum of tongue looks glossy - atrophic tongue
◦ Don’t see much dental papilla (taste bud) • What condition could cause this?
◦ ____, malnutrition, medication
For anemia, HIV, leukemia - all of these conditions we need blood work to confirm
Bottom right: see ulcer, little bit of pseudomembrane (1cm)
• How long do you think it will take to heal?
◦ Usually within 2 weeks, b/c thats how long for tissue turnover • If this stays for over months what do you worry about
◦ Healing process not happening - may be ____
◦ So if see this lesion need to ask duration/how long it’s been there
‣ Is there any change in size or texture? Is there any other ulcer in the mouth or anywhere in body? Then your ddx changes
leukemia
cyclosporine
phenytoin
leukoplakia
homogenous
HIV
anemia
cancer
Blood sample processing
Asks how many of us have experience working in a lab (bench work). Then asks if we dealt with blood. (Students give their examples of how they took blood)
She used to work on platelets of patients - took their blood and then gave them $25.
Anyways - take blood, then ____
• then will see erythrocytes in the ____ of the tube and then they’re going to check it
centrifuge
bottom
She doesn’t think much has changed in this group
• in the lab they have different ____ of the lid, and accordingly will check ____ status, the
chemistry, the ____
(If I had to guess maybe just know the color cap and the common test in right column, but she spends less than 30 seconds on this slide)
color
coagulation
glucose
What is the “normal” value?
▪ No standard to “normal”
§ Approximately 5% of the test results can be expected to fall
outside the ____ range for purely statistical reasons.
▪ Reference values vary with:
§ Individual ____, instrumentation, methodology
§ ____-dependent variability (e.g., time of day, position)
▪ HIGH vs. LOW vs.CRITICAL VALUE
Be very careful when using “WNL” which means Within Normal Level
But when you see the patient’s mouth there is no ____, each patients anatomy/mouth is different, tongue is different - there is no WNL in the tissue
• So for WNL the concept is coming only from ____ tests
◦ So wouldn’t advise using WNL within a patients note.
◦ Just say “no significant abnormality”
◦ Very fine line b/ween normal and abnormal
As she said: certain reference (normal) values you need to memorize it
• Is it higher than normal or lower
• Another way they put the critical value and the different color in the computer - they will show you
◦ Not always necessary that have to treat high value, but if ____ high or way way higher then need further investigation
normal
laboratories
patient
WNL
laboratory
consistently
Rationale for laboratory testing
▪ \_\_\_\_ ▪ Cost-effectiveness ▪ Labor \_\_\_\_ ▪ Sensitivity vs. Specificity § The ability to correctly identify asymptomatic members of a population ▪ Sensitivity: true \_\_\_\_ rate ▪ Specificity: true \_\_\_\_ rate
• Has to be convenient, and has to be cost-effective
◦ So if you want to do biopsy (let’s say leukoplakia on the tongue) - do you know how much it costs for
patient?
◦ So #1 want to do biopsy, so procedure ____ should be charged - so this charge goes to surgeon or
dentist who did the biopsy
◦ Biopsy specimen sent to lab - pathologist has to process the specimen (make a slide) and take a look
at histology
‣ Sometimes they have to use very expensive ____
‣ Do you know pemphigus/pemphigoid? so are you familiar with immunofluorescence?
• So pemphigus/pemphigoid are both blistering disease in the mouth. To differentiate the two, need to do immunofluorescence study
◦ Immunofluorescence study is not only routine H&E - so whole cost to patient
◦ Procedure cost may be $150, but lab fees can be $800-1000
◦ But it’s necessary if have pemphigus/pemphigoid
‣ So should always consider if really necessary for patient to do all this expensive lab tests including biopsy
◦ Have we heard of brush biopsy - done in mouth and much cheaper - but can’t tell you if ____ or not
◦ Brush biopsy can only tell you if shows ____ cells or not
convenience
efficiency
positive
negative
code
staining
cancer
atypical
Sensitivity vs specificity
SHE IS GOING TO ASK ON THE TEST!!! Sensitivity = how much true ____ you can pick
Specificity = how much true ____ you can pick
• There are many good websites talking about this
◦ Example: surgeon can use ‘toluidine’ (I think this is what she said) blue staining - can be used before biopsy to identify the margin of the cancerous lesion
‣ It’s a kind of a cancerous detector - put it on suspicious area and cancerous lesion will be stained
• It has a very high ____ = even frictional keratosis or benign lesion often will stain
◦ So the sensitivity is too high
• The specificity is relatively ____
‣ Want both the sensitivity and specificity to be as ____ as possible • Thats a selling point of lab tests
positive negative sensitivity low high
Just in case someone misunderstood this part - component is a little bit different
Majority of transplant nowadays for cancer patient is actually ____ transplant, b/c ____ transplant is more invasive
peripheral blood
bone marrow
Peripheral blood cells
▪ The ____ components of blood, consisting of red blood cells (erythrocytes), white blood
cells (leucocytes), and platelets, which are found within the circulating pool of blood
▪ Not sequestered within the ____ system, spleen, liver, or ____ marrow.
Most of the time we are talking about peripheral blood cells
• Not talking about the blood within the spleen, bone marrow, or other systems
◦ Function of spleen - get rid of old blood cells
• When take blood from certain organs, the components are different
• But we will be talking about the normal peripheral blood cells
cellular
lymphatic
bone
Formed elements of the blood
So this is formed elements of the blood
• ____: always in this shape
• ____
• And ____
RBC
platelets
WBC
When we talk about about CBC with differential - there is a meaning
• Want to know how much neutrophil, how much monocyte, basophils, etc
◦ Most important one for us is ____!
‣ REMEMBER: neutrophil you have to know everything
‣ Why neutrophil? B/c major one to fight ____
• If neutrophil is not high enough then body can’t fight
• For chemotherapy with cancer patient - their neutrophil count may be down to
zero, so they very susceptible to ____ - so they aren’t just walking around So neutrophils number will be another one that will have to memorize!!!
neutrophil
infection
infection
Complete blood count (CBC)
- WBC
- Hgb
- Hct
- RBC
- RBC indices
- ____ (MCV)
- mean corpuscular hemoglobin (MCH)
- ____ (MCHC)
- red cell distribution width (RDW)
- platelet count (PLT)
Complete blood count before the electronic chart generation - everything was handwriting
• Used to use this type of shape to identify WBC, Hemoglobin (HgB), Hematocrit (HCT), and platelets
◦ This shape even today need to know which is which What can you tell from Hgb and HCT?
• ____
What can you tell from WBC count?
• ____
• ____ - have higher WBC count
Platelets count?
• Important, remember ____ thousand count (per microliter)
For RBC have indices - will talk about later. Have to know what it means, but don’t have to memorize everything.
mean corpuscular volume
mean corpuscular hemoglobin concentration
anemia
infection
leukemia
150-400 thousand
White blood cell (WBC)
▪ Leukocytes
▪ Normal value: ____
▪ Approximately ____% of the blood volume
▪ Specific roles in the human immune system
▪ Life span ranges from ____ days, after which time they are destroyed in the ____ system
Very important for human immune system
• This is not forever, all the blood cell tissue has turnover
◦ Lifespan is about 2-3 weeks, then will be destroyed in lymphatic system
◦ Should be renewed every time
4.0-10.5 X 10E3/uL
1
13 to 20
lymphatic
