NSG 550 EXAM 1 Flashcards
- Process of clinical reasoning and determining differential diagnoses in the role of an NP
● Clinical reasoning occurs in clinical practice through thinking and decision-making processes.
● Knowledge + cognition= metacognition required for clinical reasoning.
● Knowledge is theory and research, personal, and professional experience.
● Cognition is reflective inquiry.
● Metacognition combines knowledge and cognition
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- Application of sensitivity vs specificity to diagnostic testing and appropriateness
Accuracy
– Does the test measure what it was designed to measure?
– Proportion of all tests (positive and negative) that are correct.
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- Application of sensitivity vs specificity to diagnostic testing and appropriateness
Precision
– Does the test reproduce the same results when repeated on the same patient or a sample? A
– test can be precise but not necessarily accurate if the results differ from reference range.
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Sensitivity
– True positives ÷ (True positive + False negative)
● Measures proportion of true positive (diseased) with a positive test result
● Those with disease
● A high sensitivity test means that it detects the presence of a condition with relatively few indicators (depends on the key point evaluated in the test)
● Among people with disease, how often is the test right?
● Example
● Test A has a sensitivity of 0.8 or 80%
● Test A correctly identifies 80% of the people who have the disease
● But it misses 20%. → 20% have the disease but the test did not detect it
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Specificity
– True negatives ÷ (True negatives + False Positive)
● Measures proportion of true negative (non-diseased) with a negative test result
● Those who are well / disease free
● A highly specific test means that it really rules out a diagnosis if a patient does not have the indicators
● Among people who are well, how often is the test right?
● Example
● Test A has a specificity of 0.8 or 80%
● Test A correctly identifies 80% of the people who do NOT the disease
● But it misidentifies 20%. → 20% do NOT have the disease but the test said they did
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Disease + Positive Test = True Positive
Disease + Negative Test = False Negative
No Disease + Positive Test = False Positive
No Disease + Negative Test = True Negative
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- American College of Radiology Appropriateness Criteria-understand the categories for procedures as they relate to 1) appropriateness rating and 2) radiation level.
● “Why?” → Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition
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○ 1) Appropriateness Rating
■ Appropriateness Category Names and Definitions
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■ 2) Radiation Level
● Relative radiation level designations along with common examples of each classification
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: Usually Appropriate
Appropriateness Rating: 7. 8. or 9
Approp. Category Definition:
The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: May Be Appropriate
Appropriateness Rating: 4, 5, or 6
Approp. Category Definition:
The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: May Ba Appropriate (Disagreement)
Appropriateness Rating: 5
Approp. Category Definition:
The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: Usually Not Appropriate
Appropriateness Rating: 1, 2, or 3
Approp. Category Definition:
The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
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- Steps to patient safety in the management of diagnostic studies/follow up to patients with results
timeliness in reporting test results is no less essential. To be clinically useful, results must be reported promptly. Delays in reporting test results can make the data useless. The data must be included in the appropriate medical record and presented in a manner that is clear and easily interpreted.
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
X-Ray:
Beam of X-rays (highly charged electrons) that is passed through the body.
● High Density objects appear white (bone)
● Low Density objects appear black (lung)
● Radiation–★
● Cost – $
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
CT Scan:
A series of cross-sectional X-rays (360 degree view)
● Helps image bone, soft tissue, and vasculature at the same time
● High Density = White
● Low Density = Black
● Radiation– ★★★
● Cost – $$
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
CT (With Contrast):
Contrast helps highlight specific areas of interest - areas with contrast will ‘light up’ on CT
● PO (Oral) Contrast
○ Helps differentiate areas of GI Tract from surrounding soft tissue, blood vessels, etc.
● IV Contrast
○ Helps differentiate between normal and abnormal blood vessels
○ Aid in describing an abnormality such as tumor that might have own vasculature
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
Ultrasound:
High frequency sound waves are bounded off of tissue in our body, and are used to create cross-sectional image of the body
● Quick, easy, portable method of visualizing body cavities, tissues, and blood vessels [[[anywhere w/ fluid ]]]
● Radiation: NONE
● Cost: $
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
US With Doppler:
Doppler effect: Object traveling towards you has a higher frequency
● Can be applied to Ultrasound of blood vessels to assess for blood flow
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
MRI:
Large magnetic fields are used to manipulate hydrogen atoms in our soft tissues, creating 3D maps
● Best for visualization of the brain, spinal cord, and other soft tissue
● Radiation: NONE
● Cost:$$$$
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Patient follow-up with results
o Do not give over the phone, or on answering machine
o Do not give to family/friends unless written consent is given
o Provide education on meaning of results, disease process, home care, next visit,
and treatment options
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Precision:
does the test reproduce the same results when repeated on the same patient or a sample; a test can be precise but not necessarily accurate if the results
differ from reference range
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Specificity:
among people who do not have the disease, how often is the test
right?
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Sensitivity:
among people who have the disease, how often is the test right?
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Accuracy:
does the test measure what it was designed to measure; proportion of
all tests (positive and negative) that are correct.
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Clinical decision making is multifaceted and encompasses the patient, clinical
problem, and the practitioner’s perspectives
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Critical thinking involves application of analysis, evaluation, and inference
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Knowledge + cognition = metacognition
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Collect H&P, complete physical exam, interpret diagnostic studies
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- Blood studies
o Used to establish Dx, r/o clinical problem, monitor therapy, establish prognosis,
screen for disease
o Venous – most common
o Arterial – causes more discomfort, used for blood gasses, higher risk of hematoma
– hold pressure longer
o skin puncture – often used in pediatrics, mix of venous and arterial. Earlobe can
be used for arterial if needed. Do not milk d/t hemolysis
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Electrodiagnostic studies
o Tests electrical impulses
o May cause discomfort from stimulation
o Do not move, have caffeine or sedatives before test
o Few complications
o Not invasive, usually do not need written consent
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- Endoscopy
o Need written consent
o Baseline labs
o Prep depending on type of study
o Like minor surgery (educate re: sedative, have emergency equipment available,
need ride home)
o IV antibiotics for those with prosthetic joints or cardiac valve disease
o Education – may cause gas, discomfort, infection signs
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- Fluid Analysis Studies
o Normal fluids and effusions
o Aspiration must be sterile
o Diagnostic and therapeutic
o Risks: infection, seeding of malignancies, leakage, reflex bradycardia/hypotension
from anxiety
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- Manometric Studies
o Measure and record pressures
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- Microscopic Studies
o Biopsy, culture/smear (STIs, TB, etc.), pathologic conditions (liver, renal,
urological), PAP
o Gram staining and shape (Gram neg rods = e coli)
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- Nuclear Scanning
o Stage cancer, detect sites of GI bleed, diagnose cholecystitis/pulm embolism,
brain scan, eval gastric emptying/thyroid nodules/testicular swelling/cardiac
function
o Technetium-99m (99mTc) is used extensively in nuclear scanning because its
half-life is 6 hours and it emits low levels of gamma rays. Other commonly used
radionuclides include gallium, thallium, and iodine.
o Combined with a transport molecule that takes the radionuclide to the intended
organ
o Superimpose of baseline CT/PET to see hot and cold spots
o Normally uptake is consistent across organ
o SPECT gives 3D images
o Radiation risk but less than x-rays
o Contraindicated in pregnant and nursing
o Use toilet and flush several times after use, clean up spilled urine, wash hand
thoroughly, wash soiled clothes separately
o Assess for allergy
o Oral, inhaled or IV admins of radionuclide
o Encourage water drinking
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- US
o Used to determine if lump is fluid or solid, guide needle biopsy, stage tumor, eval
pregnancy/placenta, detect ectopic pregnancy, determine fetus status/size, eval
arterial or venous disorders
o No radiation and less costly than CT or MRI
o B-scan, M-mode scan (motion), Real time imaging, doppler (amplifies sound
waves), color flow doppler (direction of flow), duplex scanning (real time + color
flow), 3D (pregnancy)
o Air, fat, and movement get in the way of good image
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- Urine
o Used to dx renal, urinary tract, metabolic disease
o 1st morning – void before bed then in AM. Best for protein, nitrates
o Random – convenient
o Timed – after meal (2hpp), urobilinogen (between 2 and 4pm). Discard void then
start timer and collect all until end time
o Double voided – fresh urine
o C&S – sterile container and cleaning of meatus. Midstream
o 24hr. discard 1st of day, then start collection, including next days AM void. Keep
on ice or fridge
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- X-ray
o Used to eval dye excretion in urinary tract/arterial occlusion/GI tract with barium/
bone disorders/ tracheobronchial tree/pulm and cardiac systems/abd pain or
trauma, detect breast cancer, guide needle biopsy, determine patency of fallopian
tubes
o Plain
o Fluoroscopy – can view motion, barium movement, more radiation
o Tomography – CT, xrays make cross sectional 3D image
o Contrast – barium, iodine, etc.
▪ Iodine contraindications – renal disease (check BUN and create 1st), DM
causes renal concerns, allergy to shellfish, dehydration,
pheochromocytoma (htn)
- Can premedicate with Benadryl and prednisone in those with
allergy hx. Use nonionic contrast - Iodine can cause lactic acidosis – must stop oral
antihyperglycemics for 48 hrs before and after
o Digital subtraction angiography – type of fluoroscopy w/ catheterization of vein
or artery. Before/after vascular/tumor surgery
o Barium – interferes with other tests, prep required before and after.
▪ Contraindicated in perforation (can use gastrografin instead) and colitis
o Nephrotoxicity d/t contrast medium – increase in serum create by more than 25%
w/i 3 days. Hydrate, use low osmolar nonionic medium in minimal amount. Do
not give diuretics
o Radiation dose – higher with CT than xray. Depends on length of time and
number of images. Dental and DEXA very low
▪ Minor reaction (n/v, urticaria) Give antihistamine
▪ Intermediate reaction (mouth/throat edema, bronchospasm, chest pain,
chills/fever) Give antihistamines and maybe steroids, fluids,
bronchodilators
▪ Severe reaction (edema, hypotension, MI, arrythmia, seizure, resp failure)
Give antihistamines, steroids, fluids, bronchodilators, intubation/vent,
pressors, antiepileptics
▪ Delayed reactions can occur for 2-6hrs
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- MRI
o No radiation
o Advantage over CT – better contrast image, no obscuring bone, natural blood
vessel contrast, can image multiple angles
o Evals most body systems – brain, GI, muscle, cardiac, breast, spine
o Expensive and labor intensive
o Can use contrast like gandolinium or gasoxetate
▪ Should check renal function, especially in those over age 60
o Contraindicated in extreme obesity, claustrophobia, agitation, metal in body
o Remove patches and any metal, remain still
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Urologic/Renal
* Imaging studies
o KUB – not specific
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Urologic/Renal
* Imaging studies
o Pyelography – mostly replaced with CT.
▪ X-ray that uses contrast injected into renal system or IV.
▪ Indicated for stones, hematuria, trauma, outlet obstruction, tumor, pelvic
surgery
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Urologic/Renal
* Imaging studies
o Renal scan
▪ Nuclear study - Radioisotope and scintillation camera
▪ No iodine, safe to use in renal disease and allergies
▪ Perfusion, structure, function, hypertension, or obstruction
▪ Not to be done w/I 24 hrs of IVP
▪ Evaluate transplant rejection
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Urologic/Renal
* Imaging studies
o Cystoscopy
▪ Camera in bladder
▪ Used for hematuria, recurrent UTI, dysuria, frequency, retention,
inadequate stream, urgency, incontinence
▪ Diagnostic
- Ureter sample collection, visualization, measurement, calculi
▪ Therapeutic
- Resection of tumors, removal of FB, dilation, stent placement,
coag of bleeding, implant radium seeds, TURP
▪ Urethroscope, cystoscope, ureteroscope. Nephroscope
▪ Complications – perforation, sepsis, hematuria, retention
▪ Assess voiding for 24 hrs, note urine color (pink tinge common) avoid
standing immediately after, burning during urination common (should pee sitting), drink fluids, observe for sepsis, may use antibiotics before and
after, avoid constipation
▪ Tumor, stones, prostate hypertrophy/cancer, inflammation, stricture
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- Interpreting a Urinalysis
▪ Appearance: clear
* Cloudy d/t pus or foods (fat, urates, phosphates)
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- Interpreting a Urinalysis
Color: amber yellow
- Kidney bleed- dark red
- Lower bleed – bright red
- Urobilinogen or bilirubin – dark yellow
- Pseudomonas – green
- Beets/rhubarb – red/brown
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- Interpreting a Urinalysis
▪ Odor: aromatic
- DKA – acetone
- UTI – foul
- Enterobladder fistula – fecal
- PKU - musty
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- Interpreting a Urinalysis
▪ pH: 4.6-8.0 (average, 6.0)
- acid base balance, foods
- acidic urine associated with zanthine, cystine, uric acid and
calcium oxalate stones - alkaline urine associated with calcium carb/phos and mag phos
stones. UTI - urine become alkaline on standing
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- Interpreting a Urinalysis
▪ Protein: 0–8 mg/dL; 50–80 mg/24 hr (at rest); <250 mg/24 hr (during
exercise)
- Presence indicates glomerular capsule injury
- During pregnancy - preeclampsia
- Proteinuria and edema – nephrotic syndrome
- If random elevated, do 24 hr
- Usually checked with creatinine
- Orthostatic proteinuria
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- Interpreting a Urinalysis
▪ Specific gravity: Adult: 1.005–1.030 (usually, 1.010–1.025)
- Elderly: values decrease with age
- Newborn: 1.001–1.020
- High means concentrated and low means dilute
- SIADH – elevated SG
- DI – decreased SG
- Renal disease causes dilute
- Easier to check than osmolality
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- Interpreting a Urinalysis
▪ Leukocyte esterase: negative
- Pos (>100,000) = UTI, contamination by vaginal secretions
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- Interpreting a Urinalysis
▪ Nitrites: none
- Pos = UTI
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- Interpreting a Urinalysis
▪ Ketones: none
- Pos = poorly controlled DM and hyperglycemia, infection,
ketoacidosis r/t alcoholism, fasting, aspirin toxicity, anesthesia
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- Interpreting a Urinalysis
▪ Bilirubin: none
- Pos = gallstones
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- Interpreting a Urinalysis
▪ Urobilinogen: 0.01–1
- pH can affect urobilinogen levels. Alkaline urine indicates higher
levels; acidic urine may show lower levels.
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- Interpreting a Urinalysis
▪ Crystals: none
- Uric acid = gout
- Phosphate/calcium = parathyroid abnormality
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- Interpreting a Urinalysis
▪ Casts: none
- Hyaline or granular – exercise
- Fatty – glomerular disease
- Waxy – chronic renal disease
- Epithelia (renal tubular) – tumor, infection, polyp of bladder
o Most suggestive of renal tubular disease or toxicity.
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- Interpreting a Urinalysis
▪ Glucose: Fresh specimen: none
- 24-hour specimen: 50–300 mg/24 hr or 0.3–1.7 mmol/day (SI
units) - Pos = common in pregnancy, hyperglycemia, renal glycosuria,
Fanconi syndrome, nephrotoxic chemicals
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- Interpreting a Urinalysis
▪ White blood cells (WBCs): 0–4 per low-power field
- Pos = UTI
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- Interpreting a Urinalysis
▪ WBC casts: none
- Pos = UTI (usually kidneys)
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- Interpreting a Urinalysis
▪ Red blood cells (RBCs): ≤2
- Pos = something causing bleed, menstruation
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- Interpreting a Urinalysis
▪ RBC casts: none
- Pos = glomerulonephritis (which may be present in patients with
acute bacterial endocarditis, renal infarct, Goodpasture syndrome,
vasculitis, sickle cell disease, or malignant hypertension),
interstitial nephritis, acute tubular necrosis, pyelonephritis, renal
trauma, or renal tumor
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- Culture and Sensitivity
o Negative: <10,000 bacteria/mL urine
o Positive: >100,000 bacteria/mL urine
o Prelim report in 24 hr, final in 48-72
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- PSA
o <2.5 is low, >20 is very high
o Early detection and monitoring of prostate cancer
o 80% false positive
o Bound PSA more indicative of cancer than free PSA
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- Serum Carbon Dioxide Level (23-30)
o Part of electrolyte studies
o Regulated by kidneys
o Increase = alkalosis
o Decrease = acidosis (renal failure)
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- Testing to diagnose and manage CKD
o Urine albumin
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- Testing to diagnose and manage CKD
o Serum Creatinine (0.5-1.2 mg/dl)
▪ >4 mg/dL (indicates serious impairment in renal function)
▪ Normal differs by sex, age: lower in children
▪ Trough at 7am, Peak at 7pm,
▪ Higher after meal
▪ Dehydration and diet high in meat causes elevation
▪ Increased: Diseases affecting renal function, such as glomerulonephritis,
pyelonephritis, acute tubular necrosis, urinary tract obstruction, reduced
renal blood flow (eg, shock, dehydration, congestive heart failure [CHF],
atherosclerosis), diabetic nephropathy, nephritis. Also, rhabdo/increased
muscle mass diseases
▪ Interpreted with BUN: BUN/Create ratio normally 6-25 (15.5 optimal)
▪ Used to estimate GFR
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- Testing to diagnose and manage CKD
o BUN (7-20)
▪ Formed in liver and excreted by kidney
▪ Low in liver disease, high in kidney disease
- Testing to diagnose and manage CKD
o Creatinine Clearance
▪ 90-140, higher in males
▪ Decreases by 6.5 with each decade of age after 20
▪ 24 hr urine and serum creatinine used to calculate
▪ Measure of GFR
▪ Decreased in kidney disease and anything that reduces kidney perfusion
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- Testing to diagnose and manage CKD
o eGFR
▪ Cystatin C might be better to estimate GFR than Create because its more
stable
▪ Calculated by create/CC and age, gender, race
▪ Normal around 120
▪ Below 60 indicates disease
▪ Below 15 is kidney failure
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Endocrine
- Thyroid Nodule Diagnosis and Imaging
o US can identify non palpable nodules and cysts – preferred method
▪ Malignant nodules are mostly solid and hypoechoic with irregular margins ▪ Benign nodules are well defined and hyperechoic
o Scintigraphy reserved for characterizing functioning nodules and for staging
follicular and papillary carcinomas
o Plain radiographs are used to detect retrosternal thyroid extension, thyroid
calcification, bony or mediastinal lymph nodes, and lung metastases. Limited usefulness.
o CT scanning is an effective method for detecting regional and distant metastasis
from thyroid cancer.
o MRI has a limited role in characterizing thyroid nodules, although it appears to be
effective in the diagnosis of cervical lymph node metastasis and staging cancers.
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Endocrine
- Fine Needle Aspiration of Thyroid
o Percutaneous needle aspiration remains the key procedure in the diagnosis of
thyroid lymphoma; however, thyroid lymphoma’s differentiation from thyroiditis
occasionally can be difficult. A tissue-specific diagnosis of a lymphoma can be
achieved by using US-guided FNA.
o Risks – bleeding, infection, injury to vital structures, bruises
o Might need to stop blood thinners
o Results – benign (f/u), cancerous (remove), indeterminate (repeat in few months),
inadequate (repeat in few months)
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Endocrine
- Thyroid function tests
o TSH (0.3-5)
▪ Elevated – hypothyroid ▪ Decreased – hyperthyroid ▪ Trough 10am, peak 10pm
o Thyroxine (T4) – 5-12, free 0.8-1.8 micrograms
o Triiodothyronine (T3) – 100-200 nanograms
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Endocrine
- Diabetes
o C-Peptide - evaluates islet cell function (0.5-2)
▪ Used to evaluate diabetic patients and to identify patients who secretly self-administer insulin. C-peptide is also helpful in monitoring patients with insulinomas ▪ Decreased in DM with insulin admin ▪ Usual correlates with insulin levels but more accurately reflects islet cell function in patients taking insulin
o Fasting plasma glucose, a 75-gram oral glucose tolerance test (also called the 2-
hour glucose tolerance test), and hemoglobin A1C are all valuable in
diagnosing DM
o Microalbumin – first indicator of renal disease, screen annually
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Endocrine
- Cortisol
o Diurnal variation, higher in AM (5-23), decreased after 4pm (3-13)
o Measures adrenal activity
o Cushing – does not go down during day
o Elevated – Cushing, ACTH producing tumor, hyperthyroid, obesity
o Low – Addison disease, hypopituitary/thyroid, adrenal hyperplasia
o Pregnancy, stress increases
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Endocrine
- ACTH (6-58 F, 7-69 M)
o Anterior pituitary function
o Cushing – Low=pituitary cause/High=adrenal cause
o Addison – High because adrenal not working
o Hypopituitary – Low Cortisol and ACTH
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Endocrine
- ACTH stimulation
o Evaluates the ability of the adrenal gland to respond to ACTH administration. It is
useful in evaluating the cause of adrenal insufficiency and also in evaluating
patients with cushingoid symptoms.
o Increase in cortisol after ACTH-drug indicated adrenal gland is normal but
pituitary isn’t functioning correctly
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Endocrine
- Insulin (6-26)
o Used to diagnose insulinoma (tumor of the islets of Langerhans) and to evaluate
abnormal lipid and carbohydrate metabolism. It is used in the evaluation of
patients with fasting hypoglycemia.
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Immunologic/Skeletal
- Rheumatoid Arthritis Diagnoses
o Antinuclear Antibody – tests multiple antibodies, not specific
o Rheumatoid Factor - autoantibody
o Inflammatory Markers
▪ C reactive inflammatory markers
* < 1
* Infection, infarction, autoimmune inflammation
* Rises and falls quickly
▪ Erythrocyte Sedimentation Rate
* Up to 15 M, up to 20 F
* Slower to rise and fall than CRP
* Infection, infarction, autoimmune inflammation
o X-ray – inexpensive and easy
o MRI in c-spine abnormalities
o Joint aspiration and synovial fluid analysis
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Immunologic/Skeletal
- Arthroscopic Knee Surgery
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Immunologic/Skeletal
- Vitamin D
o Total: 25-80 ng/ml
o Below 20 is deficient
o 20-30 is insufficient
o Over 200 could be toxic
o Intake
▪ Under 50 = 200iu
▪ 51-70 = 400iu
▪ 71+ = 600iuo Works with PTH to increase serum calcium
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Immunologic/Skeletal
- Bone Densitometry/Density (DEXA) Scans
o Normal: <1 SD below normal (>–1.0)
o Osteopenia: 1.0–2.5 SD below normal (–1 to –2.5)
o Osteoporosis: >2.5 SD below normal (<–2.5)
o Done on postmenopausal women every 2 years
o Annual for hyper parathyroid or long-term steroids
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Immunologic/Skeletal
- Calcium Levels (9-10.5 mg/dL, ionized 4.5-5.6)
o Used to evaluate parathyroid function and calcium metabolism, to monitor
patients with renal failure, renal transplantation, hyperparathyroidism, and
various malignancies and to monitor calcium levels during and after largevolume blood transfusions.
o When blood levels decrease, PTH is stimulated which stimulates release of
calcium from reservoirs
o Half is free and half is bound to albumin. Ionized measurements do not change
d/t albumin
o Symptoms of hypercalcemia may include anorexia, nausea, vomiting,
somnolence, and coma.
▪ Most common cause is hyperparathyriod
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Immunologic/Skeletal
- HIV Testing
o Viral load - accurate marker for prognosis, disease progression, response to
antiviral treatment, and indication for antiretroviral prophylactic treatment.
o Serology and virology: Standard for testing
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- Process of clinical reasoning and determining differential diagnoses in the role of an NP
What goes into clinical reasoning - understanding of the situation, knowledge of disease process and findings, decision making for testing
Never guessing or “shotgun approach”
Best information is through thorough history and physical
- listen to your patients, don’t always need diagnostic testing to determine a diagnosis, use clinical practice guidelines to develop your plan of care
Coming up with a diagnosis - knowledge, experience, analyzing data (diagnostics), and looking at other differentials to keep an open mind (use these to rule in or rule out your differentials) - Example - differential diagnosis pregnancy
- Negative Hcg rules this out
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Pearl of the Day:
A retroperitoneal ultrasound is a diagnostic test used to examine the area behind the intestine and other abdominal organs. It allows the NP to view the patient’s kidneys and ureters and can help diagnose a number of conditions such as renal cysts or gallstones.
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- Application of sensitivity vs specificity to diagnostic testing and appropriateness.
Specificity - looking for patients without disease (screening test) - low false positive
Sensitivity - looking for patients with disease - low false negatives
Specific - CRP, PSA
Sensitive - Hcg
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- American College of Radiology Appropriateness Criteria - understand the categories for procedures as they relate to appropriateness rating and radiation level.
Guidelines for ordering tests based on what information you are looking for - helps with contrast vs noncontrast (renal stone protocol)
Compares radiation exposure
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- Steps to patient safety in the management of diagnostic studies/follow up to patients with results
You have an obligation for every test you order to read the FINDINGS and IMPRESSION - you are responsible for that information in regards to incidental findings as well as if there are any inconsistencies - what do you do in that situation?
Always relay information to patients as quickly as possible - normal vs abnormal
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
Ultrasound - looks at vessels (venous arterial duplex) good for ovaries and testicles, can look at soft tissue as well for abscess/cyst, thyroid
MRI - in depth look, bone tissues vessels
Microscopy - culture and sensitivity, blood culture, UA
Xray - bones and bone densitometry
Nuclear med - bone scan, thyroid scan (scintography)
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Serum CO2 - kidneys remove acid and maintain balance of HCO3
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PSA - all prostate secrete; levels by age and is screening tool (specific)
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Creatinine - removed entirely by the kidneys; best way to follow over time. Also GFR and CrCl
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Microalbumin - done by UA most commonly caused by diabetic nephropathy
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Gold Standard for first time kidney stone testing
- a non-contrast CT of the abdomen and pelvis.
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High ACTH High Cortisol - Cushing’s disease
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Low ACTH High Cortisol - Cushing’s Syndrome or adrenal tumor
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High ACTH Low Cortisol - Addison
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Low ACTH Low Cortisol - hypopituitary
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C reactive protein
- one of the proteins that activates the complement above - protein made by the liver, releases more if you have high inflammation. Can look at chronic inflammation/infection but doesn’t distinguish.
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Erythrocyte sedimentation rate
- erythrocytes (RBC), looks at how fast the RBC sink to the bottom of the tube, normally this is slow but in inflammation the RBC clump together causing them to fall faster.
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Rheumatoid Factor
- another test to look for RA used with ANA but Rheumatoid Factor is MOST SPECIFIC
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Antinuclear antibody
- antibodies that target normal proteins in the nucleus of a cell - SLE, Rheumatoid arthritis, Scleroderma, Sjogrens syndrome, Addison, autoimmune hepatitis.
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Immunological tests:
ANA
- Negative result is unlikely to have an autoimmune disorder
- Positive result doesn’t tell you what one - so it is SPECIFIC but NOT SENSITIVE
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The most important thing is your history and physical. Listen to your patients. Allow them to tell you their story. Don’t go in with any preconceived notions. Don’t have a diagnosis already in your head. Use clinical practice guidelines to develop your plan of care.
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You don’t wanna guess on things you don’t wanna do a shotgun approach if you don’t know what’s going on, and just order a bunch of stuff and see what sticks. So you always wanna go in with some degree of calculation, using your previous knowledge and understanding of the situation.
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So examples of something that is specific would be a Crp and a Psa, something that is sensitive would be an Hcg.
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We talked in week one to make sure that every single diagnostic test that you order you want to make sure that you read all of the findings and all of the impressions.
So the findings are what the radiologist sees on. The cat scan the impression is their interpretation of that. Sometimes you might see something in the finding section, but it’s not listed in the impression, because it’s not something that you specifically asked for. So when you go to order a test you have to tell them exactly what your concern is and what they are to be focusing on. If you tell them that you are concerned about diverticulitis, and they find maybe some fluid in the lung, or like a plural fusion. You may not find that in the impression, because it would be an incidental finding.
But if something happens later on and the patient decompensates because they had this plural effusion that you didn’t recognize or you didn’t notify them of, you’re gonna be the one that’s responsible for that.
So you want to read all of the findings, all of the impression. You want to make sure that you notify the patient as quickly as possible about their results, both normal and abnormal.
And if you ever come up with a question or something that you don’t understand on the radiology report. You wanna discuss it with the radiologist. Now, a days with dictation software. I find that there are often dictation errors. So they might put that somebody has something in the findings, and then, they say, doesn’t have it in the impression.
So I call radiology constantly, and I’m like there’s a discrepancy, you know. Do they have cellulitis, or do they not have cellulitis? And then they will go back, and they will amend their report and fix it, and they’re usually very grateful that you picked up on that, and that you actually read their report.
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Know that an ultrasound
is very good at looking at blood vessels. So this could be venous and arterial.
So, for example, you can do an ultrasound of the extremity because you’re worried about a DVT, you can do an ultrasound of the carotid arteries because you’re worried about stenosis.
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An ultrasound is the gold standard for reproductive organs, so testicles and ovaries.
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An ultrasound can also look at soft tissue to look for abscesses. or can look for inflammation of the muscle. If you have an abscess that has invaded into the muscle, then it can tell you whether or not there’s a myositis.
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The last thing an ultrasound is really good for is a thyroid evaluation. So if you have to evaluate, if you help paid a mass, then an ultrasound is going to be your gold standard, for as the first test.
The last thing an ultrasound is really good for is a thyroid evaluation. So if you have to evaluate, if you suspect a mass, then an ultrasound is going to be your gold standard, for as the first test.
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MRI
- is great for everything, it also takes the longest and is the most expensive.
- but it will look in-depth. Bones, tissues, and vessels!
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Know what kinds of things you can send off to microscopy.
So this is, gonna be all of your culture and sensitivity tests.
So blood tests wound cultures. I’m sorry, not blood test blood cultures. womb cultures.
Urine cultures. And UA is also done in microscopy.
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Know that a bone densitometry is a type of an X-ray
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nuclear medicine.
We already talked about a thyroid scan which is called a synthetography.
and you can do bone scans as well, which is a nuclear medical test.
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Regarding urinalysis, the physical exam portion looks at the volume, color, clarity, odor, and specific gravity.
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The chemical portion of the urinalysis looks at the pH, red blood cells, white blood cells, protein, glucose, urobili, billy
ketone bodies, leukocytesterase and nitrites.
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Microscopic portion of the urinalysis looks at casts, cells crystals and bacteria or microorganisms
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The best indicator for UTI is going to be your Wbc’s on your UA.
But for our purposes white blood cells are gonna be your gold standard for identifying a UTI.
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Serum CO2:
Very important for acid base balance. This is gonna be located on your chemistry panel. and it really gives you an early indication of what their acid-base status is. I often find that I will come behind other providers and I will look at somebody’s lab results. I’ll look at their chemistry panel, and I see that they have a low serum, and that always gives me a reason to pause because it can be a sign of early infection. It can be a sign of early respiratory compromise.
Like, if they’re creatine is trending upwards, and they are becoming more acidic, and it gives me an early sign of renal failure.
So Serum CO2 is something I look at very closely on all of my labs. Remember this.
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Remember that a Psa level is going to be specific to age. So the older you get, the more your Psa can trend up and still be normal.
All prostate glands will secrete Psa, and Psa level is a very good screening tool, because it’s very specific.
Not sensitive, but very specific.
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Creatine is your best
determination of kidney function. It’s the best way or best lab value to follow over time. And it’s because your creatine levels are entirely removed by the kidneys. From this level, you can also calculate a GFR. And a creatinine clearance
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Microalbumin:
It is noticed on UA, which is why all of your diabetics should have a urineanalysis, because an elevated micro albumin gives you an early indication for diabetic nephropathy.
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Study the gold standard for first time.
Kidney stone testing is gonna be a CT without contrast.
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Make sure that you remember your tests for diabetes so you can do a fasting blood glucose.
You can do a HGAIC, and you can do a glucose tolerance test. This is typically only done during pregnancy. I can’t remember any time that I’ve ever seen somebody have to do a glucose tolerance test to determine if they’re diabetic.
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You don’t have to be fasting for a HGA1C test.
It doesn’t matter if their diet over the past couple of days was crap.
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If the HGA1C is checked, it gives you their average value over the past 3 months.
So you don’t have to fast for that. One of the drawbacks to the HGA1C is that you have to have special lab testing in order to do it, and not all labs are qualified to run a HGA1C.
So there is that limitation.
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The best non blood test for thyroid is going to be your ultrasound.
Make sure you understand that your hyperthyroid hormones are gonna show a low TSH, and a high T4.
Your hypothyroid is gonna show high TSH, and low. T4.
Remember that cortisol is made by the adrenal glands, and that it’s a glucocorticoid hormone.
It helps to regulate stress response control. Metabolism, suppress inflammation, regulate blood pressure. Among others.
High ACTH and high cortisol is typically Cushing’s disease.
Low ACTH and high cortisol is cushing syndrome, or it can be an adrenal tumor.
High ACTH and low cortisol could be something like Addison’s.
Low ACTH and low cortisol would be hypopituitarism.
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High ACTH and high cortisol is typically Cushing’s disease.
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Low ACTH and high cortisol is cushing syndrome, or it can be an adrenal tumor.
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High ACTH and low cortisol could be something like Addison’s.
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Low ACTH and low cortisol would be hypopituitarism.
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CRP is part of the complement assay.
It’s a protein that’s made by the liver, and we use it as an inflammatory marker, so it can detect inflammation or infection, but it doesn’t distinguish between the two.
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ESR is another inflammatory marker.
Rheumatoid factor is the most specific for diagnosis of rheumatoid arthritis, but it’s used in conjunction with an ANA (anti-nuclear antibody).
If it’s negative, you are very unlikely to have an autoimmune disorder. If it’s positive you probably have an autoimmune disorder, but you don’t know which one. So it’s very specific, but not sensitive.
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Pearl of the Day: CT vs MRI
CT: A CT scan uses x-rays to create detailed pictures of organs, bones, and other tissues. With a CT scan, an image of almost the entire body, from the neck to the thighs, can be done in a few seconds. Most of the time, CT is the first choice to stage cancer. Apart from cancer, CT scans are often used to image bone fractures and look for internal bleeding or blood clots, spinal and brain injuries, and other conditions.
MRI: An MRI also creates detailed pictures of areas inside the body, but it uses radio waves and a powerful magnet to generate the pictures. MRIs excel in showing certain diseases that a CT scan cannot detect. Some cancers, such as prostate cancer, uterine cancer, and certain liver cancers, are much less visible or invisible to detect on a CT scan. Metastasis to the bone and brain also show up better on an MRI. MRI is also used for many other purposes unrelated to cancer, including injuries to soft tissue or joints, and injury or disease of internal organs including the brain, heart, and digestive organs. An MRI costs about twice as much (about $1200-$4000) as a CT scan, especially if contrast dye also is used with the MRI.
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Pearl of the Day:
The most important skill of a nurse practitioner is to take a thorough history and physical exam in addition to ordering diagnostic tests. Don’t treat the test… treat the patient!
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Pearl of the Day:
Specificity of a diagnostic test is the ability of a test to correctly identify patients without the disease.
Sensitivity of a diagnostic test is the ability of a test to correctly identify patients with a disease.
*True positive: the patient has the disease and the test is positive. True negative: the patient does not have the disease and the test is negative.
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Markers for thyroid disease include TSH and T4.
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TSH is thyroid stimulating hormone and is produced by the anterior pituitary gland.
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TSH is the most sensitive marker for thyroid disease.
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T4 is thyroxine and T4 can be bound or free.
Bound T4 is attached to proteins and becomes too large to enter the cells to be effective.
Free T4 is not bound to protein, so it can enter the target tissue and affect metabolism.
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Usually you should enter a TSH and a free T4 since the free T4 is not bound.
Serum T4 is total T4 (free plus bound).
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Screening strategies: when you find the results of your thyroid studies after ordering for your pt:
If your test is normal, no further testing is needed.
If TSH is elevated, you want to add a free T4 to determine the degree of hypothyroidism.
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If TSH is elevated, you want to add a free T4 to determine the degree of hypothyroidism.
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If your TSH is decreased, you will add a free T4 and T3 to determine the degree of hyperthyroidism.
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If your TSH plus free T4 are abnormal, you should suspect a pituitary disorder or hypothalamic disease.
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So in summary of thyroid disorders for primary hypothyroidism, you would have an elevated TSH, a decreased T4, and a normal or low T3.
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For subclinical hypothyroidism you’d have an elevated TSH and a normal T4 and T3.
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For primary hyperthyroidism you would have a decreased TSH, a usually high T4, and a normal or high T3.
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For subclinical hyperthyroidism you would have a decreased TSH and a normal T4 and T3.
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Treatment for subclinical hypothyroidism:
If the TSH is greater than 10, you want to treat to prevent conversion to primary hypothyroidism.
If the TSH is between 4.5 and 10, most research doesn’t recomment treatment. You can monitor for 6 to 12 months unless the patient becomes symptomatic.
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Treatment of hypothyroidism involves supplementing levothyroxine.
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Most common cause of hyperthyroidism is Graves disease.
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For an osteoarthritis diagnosis, patients have joint pain.
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To diagnose osteoarthritis you will see joint space narrowing or osteophytes on plain X-Rays, and pt will complain of joint pain.
Red flags regarding joint pain include abnormal pain, including intensity or duration, unusual for osteoarthritis and persistent pain. Also knee effusion. Swelling of the fingers and hand if less than 50 years old and non-menopausal. Isolated MCP involvement and/or psoriasis, and if there’s several joints affected.
These are all red flags.
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Management of osteoarthritis can include both non-pharmacological and pharmacological management.
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Non-pharm tx of osteoarthritis:
ROM strengthening, use of brace or assistive devices, cane or walker, weight loss if appropriate, and modalities such as heat, cold, or ultrasound treatments.
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Pharmacological treatment of osteoarthritis:
Use only when symptoms are present, such as NSAIDs oral and topical. Be careful in pts with GI problems, hx of GI bleed, cardiac issues, or any type of renal complications.
Injectable steroids are not recommended. APAP is not first line treatment due to clinical lack of data for pain. Opioid treatment NOT recommended.
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Get a ood hx from patients with rheumatoid arhtritis.
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There is no single test to diagnose R.A. (rheumatoid arthritis).
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Usually 3 or more joints involved in R.A.
You would have symmetrical peripheral polyarthritis.
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MCP and PIP are most characteristic of rheumatoid arthritis. (Metacarpals and proximal phalanges.)
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R.A.: Morning stiffness that lasts longer than 50 to 60 minutes.
It affects the joints and they swell, and symptoms are present for 6 weeks or longer.
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Gout: deposition of monosodium urate crystals in joints and other connective tissues. This may cause acute or chronic arthritis and/or renal stones.
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In order to daignose a UTI, if using a midstream collection, it has to be greater than 100,000 organisms.
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In order to daignose a UTI, if using a cath specimen, it has to be greater than 1,000 organisms.
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Regarding UTIs, nitrites equal bacteria; it’s specific but only 50% sensitive.
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Regarding UTIs, elevated WBCs or pyurea equals infection. It’s the most reliable indicator of infection, and it is 95% sensitive of a UTI.
If you see WBC CAS, then this is significant for pyelonephritis.
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For leukocyte esterase urinalysis it’ll be a positive test for enzymes and WBCs usually indicates a UTI, and is 60 to 90% specific for a UTI.
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Most important thing is to do a comprehensive health history and physical exam. And from there you can then choose diagnostic testing.
-
You need to know what diagnositc tests are pertinent for your patient, what the findings would mean, and what, according to those findings, what further testing you would need to order.
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You need to know what diagnostic tests are in certain categories.
What is a mammogram? An X-ray of the breast.
A thyroid US is an ultrasound.
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What do you do about incidental findings? They may need further work-up; you follow-up on them, don’t ignore them.
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Do not disregard the statement/results if an incidental finding appears.
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What diagnostic tests are important for a patient with diabetes.
Know the rationale for ordering tests.
Know what specific patient instructions are needed for when you send these patients for diagnostic testing.
Are they to be NPO for 8 hours, 12 hours?
Are they to take certain medications?
Just have a global knowledge of some of the patient education instructions.
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If a patient was having stones and low back pain and hematuria, what test would you order?
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CBC- RBCs, WBCs, hgb, hct, platelets, mean corpuscular volume (MCV).
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Hemoglobin - measurement of RBCs as oxygen carrying capacity. 14-18 in men, 12-16 in women.
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Hematocrit - percent by volume (3xHgb) 42-52% 37-47%
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MCV - Size of the RBC
Low - iron deficiency, lead poisoning, thalassemias,
High - megaloblastic anemia, folate or B12 deficiency, liver disease, post splenectomy, hypothyroid, chemotherapy.
Normal - hypovolemic or blood loss.
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MCHC - concentration of hemoglobin per erythrocyte
Normal - blood loss, folate and B12 deficiency
Hypochromic - iron deficiency and thalassemia
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Platelets -
thrombocytopenia - decreased platelets
thrombocythemia - increased platelets
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WBCs
Low - autoimmune, bone marrow suppression, cancer
High - infection, inflammation
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Differential -
Neutrophils (main defense against infection) (bands/segs or PMN)
Bands - immature neutrophils released after injury or inflammation. Indicates an acute inflammatory response. "Left shift" is an increase in the number of bands (immature neutrophils. Normal amount is 0-4 present.
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Lymphocytes -
B-cells - invading viruses, bacteria or toxins
T-cells - can target and destroy own cells (cancer), as well as cells that are infected by virus/bacteria. 16-45%. (Higher in viral or TB)
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Monocytes - kill bacteria and viruses, boost immune response, and clear away dead cells. 2-10%
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Eosinophils - kills parasites and infection but also involved in allergies and help control inflammation. 0-7%.
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Basophils - release enzymes during allergic reactions and asthma attacks. 0-2%
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Reticulocyte count - new cells released by the bone marrow. Used to assess bone marrow function and can indicate rate and production of RBCs (0.5-1.5%)
Abnormals could mean sickle cell or bone marrow abnormalities.
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Cold agglutinin - type of antibody that the immune system makes to fight infection, but when they target the RBC instead it can cause anemia.
Autoimmune hemolytic anemia - mycoplasma pneumonia, HIV, epstein-barr virus, influenza.
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Anticardiolipin antibodies - antibodies that targetcardiolipins causing clotting. Think antiphospholipid syndrome (APS) or Lupus.
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Antinuclear antibody (ANA) - antibodies that target normal proteins in the nucleus of a cell: examples include SLE, Rheumatoid arthritis, scleroderma, Sjogren’s syndrome, Addison’s, autoimmune hepatitis.
Negative - unlikely to have an autoimmune disorder
Positive - doesn’t tell you which one, meaning it’s SPECIFIC but NOT SENSITIVE.
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Anti-DNA antibody: antibodies that bind to DNA. Lupus dx or flare.
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Anti SS-A, SS-B, and SS-C antibodies:
Antibodies directed against SSA and SSB autoantigens in Sjogrens or SLE but can also indicate systemic sclerosis, idiopathic inflammatory myopathies, interstitial lung disease, mixed connective tissue disorders, primary biliary cholangitis, and rheumatoid arthritis.
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Alkaline phosphatase: can be found in different parts of the body (most notably the liver) but can be bones, kidney, and digestive system as well. If no other elevated liver enzymes, think bone such as Paget’s disease (weak and brittle). Can be elevated in lymphoma or heart failure as well.
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Complement assay: measures the activity of a variety of proteins. C1-C9. Looks at autoimmune disorders, lupus, RA.
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C-Reactive Protein: one of the proteins that activates the complement (C1-C9). It’s protein made by the liver, and releases more if you have high inflammation. Can look at chronic inflammation/infection but doesn’t distinguish.
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Erythrocyte sedimentation rate (ESR): erythrocytes (RBCs), looks at how fast the RBCs sink to the bottom of the tube. Normally this is slow but in inflammation the RBCs clump together causing them to fall faster.
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HIV RNA quantification: Viral load. Looks at how well HIV is managed and response to treatment. The gold standard is that we are looking for an “undetectable” load.
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HIV serologic and virologic testing: Antibody testing that looks for antibodies to HIV.
(ELISA) - rapid test blood or saliva and can detect in 23-90 days.
Antigen/antibody test looks for both HIV antigens and antibodies. 18-45 days
Nucleic acid testing can determine positivity as well as viral load (recent exposure with negative antigen or antibody test - can diagnose in 10-33 days.
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CRP doesn’t distinguish between inflammation and infection.
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The fastest test you can do to detect HIV takes 10-33 days, and that is the nucleic acid testing.
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Immunoglobulin quantification: antibody testing. Helps to determine autoimmune issues, bone marrow suppression, and chronic conditions.
IgM - first ab after exposure: short-term protection.
IgG - needed to fight infections, account for majority of the IGs, allows your body to respond if you are exposed to the same pathogen in the future.
IgA - protects the respiratory tract and digestive system
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Lupus anticoagulant: looks for antibodies that cause clotting disorders. Usually used in conjunction with ANA testing.
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Lyme disease: An assay that looks at antibodies to Lyme disease. Not always necessary. May be better to just treat the patient symptomatically.
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Rheumatoid Factor assay: Another test that looks for RA; used with ANA but Rheumatoid Factor is MOST SPECIFIC.
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Uric Acid: Gout vs RA. Gout is inflammatory but not autoimmune, so this test helps to distinguish the difference.
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Vitamin D: supplementation has shown to decrease autoimmune diseases such as RA, polymyalgia rheumatica, autoimmune thyroid, and psoriasis.
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Arthroscopy: diagnose and treat joint problems. Inflammation, injury (tears or loose cartilage).
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Nerve conduction studies: Identifies nerve damage. Can also do electromyography (EMG) for nerve testing as well; measures electrical impulses along a nerve.
Can diagnose Guillain Barre, Carpal Tunnel, Carcot, Marie Tooth disease, polyneuropathy.
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Fluid analysis studies
Alpha defensin test: looks at protein in a prosthetic joint to assess for infection (synovial fluid).
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Fluid analysis studies
Arthrocentesis with synovial fluid analysis:
- color [clear]
- clarity [transparent]
- viscosity [High]
- WBCs [<200]
- PMN [<25%]
- crystals [none]
- gram stain [negative]
- culture [negative]
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Bone scan: nuclear imaging to diagnose bone disease. Can find metastatic cancer, sometimes infection.
-
Anytime we use “scan,” we’re talking nuclear imaging.
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Can do X-Ray of joint or bone.
XR of joint: can tell if excess fluid, fracture that goes into the joint, or osteoarthritis.
XR of bone: can tell things like chronic bone issues like chronic osteomyelitis, fractures.
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CT scan: spine, neck, extremities. With or without contrast.
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MRI: can tell more information than CT scan. Looks at bones, tissue, muscle, tendons.
Much more time-consuming and expensive.
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Never guess or use a shotgun approach.
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Best information is through thorough history and physical.
Listen to your patients
You don’t always need diagnostic testing to determine a diagnosis.
Use clinical practice guidelines to develop your plan of care.
-
Coming up with a diagnosis: knowledge, experience, analyzing data (diagnostics), and looking at other differentials to keep an open mind (use these to rule in or rule out your differentials).
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You always want to come up with your diagnosis and differentials, and then order your studies based off what you thinks the most likely problem.
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Specificity looks for patients without disease (screening test).
- Low false positives
CRP and PSA are SPECIFIC
-
Sensitivity looks for patients with the disease
- Low false negatives
Hcg is SENSITIVE
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American College of Radiology:
Contrast vs non-contrast (renal stone protocol)
-
American College of Radiology:
Compares radiation exposure.
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For every test you order you have an obligation to read all of the findings AND all of the impressions.
You are responsible for that information in regards to incidental findings as well as if there are any inconsistencies: what do you do in this situation? Make sure you call and question radiology and ask questions if there are any inconsistencies.
Always relay information to patients as quickly as possible, sharing both normal and abnormal results.
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If you ever come up with a question or something that you don’t understand on the radiology report, you want to discuss it with the radiologist.
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An ultrasound is very good at looking at blood vessels. (venous and arterial duplex), good at checking vessels on ovaries and testicles, and can look at soft tissue as well for abscesses/cysts, inflammation of muscles, and US is also good for thyroid evaluation.
An ultrasound is the gold standard for looking at reproductive organs (testicles and ovaries)
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MRI is great for everything. It also takes the longest and is the most expensive.
Takes an in-depth look at bones, tissues, and blood vessels
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Know what you can send off to microscopy.
- Culture and sensitivity, blood/wound/sputum/urine cultures, UA
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Know that a bone densitometry is a type of an X-Ray
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Nuclear med: this includes scans like bone scans, thyroid scans (scintography)
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Make sure you know what your components are to a Urinalysis
- physical exam portion looks at volume, color, clarity, odor, and specific gravity
- chemical exam portion looks at pH, RBC, WBCs, protein, glucose, urobilinogen, bilirubin, ketone bodies, leukocyte esterase, and nitrites
- microscopic exam portion looks at casts, cells, crystals, and micro-organisms.
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The best indicator (Gold Standard) of diagnosing a UTI is going to be WBCs on your UA.
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Serum CO2: very important for acid-base balance. Gives you an early indication of what their acid-base is.
Low serum CO2 could be a sign of infection, or early respiratory compromise.
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PSA: all prostrate gland secret it.
PSA level is specific to age. The older you get, the more your PSA level can trend up and still be normal.
Testing PSA level is a very good screening tool because it’s very specific, not sensitive.
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Creatinine is your best determination of kidney function.
Best lab value to follow over time, because the creatinine level is entirely removed by only the kidneys.
From this level you can also calculate a GFR and creatinine clearance.
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Microalbumin: noticed on UA.
All of your diabetics should have a UA because elevated microalbumin gives you an early indication for diabetic nephropathy.
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The gold standard for first-time kidney stone testing is going to be a CT without contrast.
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Tests for diabetes:
- fasting glucose
- HGA1C: you don’t have to be fasting, doesn’t matter if the diet over the last couple days was crap. Requires special lab testing in order to do it, and not all labs are qualified to run a HGA1C.
- GTT (glucose tolerance test); typically only done during pregnancy
- random glucose
Know what qualifies for diagnosis and what is important about each test.
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The best non-blood test for thyroid is going to be your ultrasound.
-
Hyperthyroid: low TSH and high T4. s/s
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Hypothyroid: high TSH and low T4. s/s
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Remember that cortisol is made by the adrenal glands, and that it is a glucocorticoid hormone. It helps to regulate stress response, control metabolism, suppresses inflammation, regulate blood pressure and sugar, and affects sleep/wake cycle.
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Rheumatoid factor is the most specific test for RA, but used in conjunction with an ANA.
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If ANA is negative you are very unlikely to have an autoimmune disorder.
If it’s positive your probably have one but you don’t know which one it is. So it’s very specific but NOT sensitive.
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