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«Drew Provan Andrew Krentz OXFORD UNIVERSITY PRESS OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Clinical and Laboratory Investigation Oxford ...»

-- [ Page 1 ] --

Oxford Handbook of

Clinical and Laboratory

Investigation

Drew Provan

Andrew Krentz

OXFORD

UNIVERSITY PRESS

OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of

Clinical and

Laboratory

Investigation

Oxford University Press makes no representation, express or implied, that

the drug dosages in this book are correct. Readers must therefore always

check the product information and clinical procedures with the most up- to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regula- tions. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work.

i Except where otherwise stated, drug doses and recommendations are for the non-pregnant adult who is not breast-feeding.

Oxford Handbook of Clinical and Laboratory Investigation Drew Provan Senior Lecturer in Haematology, St Bartholomew’s and The Royal London Hospital School of Medicine & Dentistry, London, UK Andrew Krentz Honorary Senior Lecturer in Medicine, Southampton University Hospitals NHS Trust, Southampton, UK 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris São Paolo Singapore Taipei Tokyo Toronto Oxford is a trade mark of Oxford University Press Published in the United States by Oxford University Press, Inc., New York © Oxford University Press 2002 The moral rights of the author have been asserted First published 2002 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press.

Within the UK, exceptions are allowed in respect of any fair dealing for the purpose of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms and in other countries should be sent to the Rights Department, Oxford University Press, at the address above.

This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, re-sold, hired out, or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser.

British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data 1 3 5 7 9 10 8 6 4 2 ISBN 0 19 263283 3 Typeset by Drew Provan and EXPO Holdings, Malaysia Printed in Great Britain on acid free paper by The Bath Press, Avon, UK Contents Contributors vi Foreword by Professor Sir George Alberti viii Preface ix Acknowledgements x Symbols & abbreviations xi Introduction: Approach to investigations xix

–  –  –

This book fills an obvious gap in the Handbook series and indeed a major lacuna in the medical literature. Too often investigations of a particular condition are lost in the welter of other text. Alternatively, they appear as specialist books in pathology and radiology. One unique feature of this book is the inclusion of all clinical investigative techniques, i.e. both truly clinical tests in the shape of symptoms and signs and then laboratorybased investigations. This stops what is often an artificial separation. Each section is clearly put together with the intent of easing rapid reference.

This is essential if the book is to have (and I believe it does have) real usefulness for bedside medicine. There are many other useful aspects of the text. These include a comprehensive list of abbreviations—the bugbear of medicine, as well as reference ranges which some laboratories still do not viii append to results. Overall, the Handbook should be of benefit to not just clinical students and junior doctors in training, but all who have patient contact. With this in one pocket, and Longmore in the other, there should be little excuse for errors in diagnosis and investigation, with the added benefit that the balance between the two will allow the upright posture to be maintained.

Professor Sir George Alberti President of The Royal College of Physicians of London July 2002

Preface

With the increasing complexity of modern medicine, we now have literally thousands of possible investigative techniques at our disposal. We are able to examine our patient’s serum and every other body fluid down to the level of individual nucleotides, as well as being able to perform precise imaging through CT, MRI and other imaging technologies. The problem we

have all faced, especially as senior medical students or junior doctors is:

which test should we use in a given setting? What hazards are associated with the tests? Are there any situations where specific tests should not be used or are likely to produce erroneous results? As medical complexity increases so too does cost; many assays available today are highly expensive and wherever possible we would ideally like to use a test which is cheap, reliable, reproducible and right for a given situation.





Such knowledge takes many years to acquire and it is a fact of life that ix senior doctors (who have attained such knowledge) are not usually those who request the investigations. In this small volume, we have attempted to distil all that is known about modern tests, from blood, urine and other body fluids, along with imaging and molecular tests. The book is divided into two principal parts: the first deals with symptoms and signs in The patient section, because that is how patients present. We have tried to cover as many topics as possible, discussing these in some detail and have provided differential diagnoses where possible. We also try to suggest tests that might be of value in determining the cause of the patient’s symptom or sign. The second part of the book, Investigations, is specialty-specific, and is more relevant once you know roughly what type of disease the patient might have. For example, if the symptom section suggests a likely respiratory cause for the patient’s symptoms, then the reader should look to the Respiratory investigations chapter in order to determine which tests to carry out, or how to interpret the results.

The entire book is written by active clinicians, rather than scientists, since we wanted to provide a strong clinical approach to investigation. We have tried, wherever possible, to cross-refer to the Oxford Handbook of Clinical Medicine, 5th edition, Oxford University Press, which provides the clinical detail omitted from this handbook. The symbol is used to highlight a cross-reference to OHCM, in addition to cross-referencing within this book.

We would value feedback from readers since there will doubtless be tests omitted, errors in the text and many other improvements we could, and will, make in future editions. All contributors will be acknowledged

individually in the next edition. We would suggest you e-mail us directly:

a.provan@virgin.net.

Drew Provan Andrew Krentz 2002

Acknowledgements

–  –  –

Why do tests?

Patients seldom present to their doctors with diagnoses—rather, they have symptoms or signs. The major challenge of medicine is being able to talk to the patient and obtain a history and then carry out a physical examination looking for pointers to their likely underlying problem. Our elders and, some would argue, betters in medicine had less tests available to them then we have today, and their diagnoses were often made solely from the history and examination. Of course, they would claim that their clinical acumen and skills were greater than ours and that we rely too heavily on the huge armoury of laboratory and other investigations available today. This, in part, is probably true, but we cannot ignore the fact that advances in science and technology have spawned a bewildering array xxi of very useful and sophisticated tests that help us to confirm our diagnostic suspicions.

By ‘test’ we mean the measurement of a component of blood, marrow or other body fluid or physiological parameter to determine whether the patient’s value falls within or outside the normal range, either suggesting the diagnosis or, in some cases, actually making the diagnosis for us.

Factors affecting variable parameters in health Many measurable body constituents vary throughout life. For example, a newborn baby has an extremely high haemoglobin concentration which falls after delivery; this is completely normal and is physiological rather than pathological. A haemoglobin level this high in an adult would be pathological since it is far outside the normal range for the adult population.

Factors affecting measurable variables

2 Age.

2 Sex.

2 Ethnicity.

2 Altitude.

2 Build.

2 Physiological conditions (e.g. at rest, after exercise, standing, lying).

2 Sampling methods (e.g. with or without using tourniquet).

2 Storage and age of sample.

2 Container used, e.g. for blood sample, as well as anticoagulant.

2 Method of analysis.

Reference ranges (normal values) These are published for most measurable components of blood and other tissue and we have included the normal ranges for most blood and CSF analytes at the end of the book.

Introduction

–  –  –

Why do tests?

Patients seldom present to their doctors with diagnoses—rather, they have symptoms or signs. The major challenge of medicine is being able to talk to the patient and obtain a history and then carry out a physical examination looking for pointers to their likely underlying problem. Our elders and, some would argue, betters in medicine had less tests available to them then we have today, and their diagnoses were often made solely from the history and examination. Of course, they would claim that their clinical acumen and skills were greater than ours and that we rely too heavily on the huge armoury of laboratory and other investigations available today. This, in part, is probably true, but we cannot ignore the fact that advances in science and technology have spawned a bewildering array xxi of very useful and sophisticated tests that help us to confirm our diagnostic suspicions.

By ‘test’ we mean the measurement of a component of blood, marrow or other body fluid or physiological parameter to determine whether the patient’s value falls within or outside the normal range, either suggesting the diagnosis or, in some cases, actually making the diagnosis for us.

Factors affecting variable parameters in health Many measurable body constituents vary throughout life. For example, a newborn baby has an extremely high haemoglobin concentration which falls after delivery; this is completely normal and is physiological rather than pathological. A haemoglobin level this high in an adult would be pathological since it is far outside the normal range for the adult population.

Factors affecting measurable variables

2 Age.

2 Sex.

2 Ethnicity.

2 Altitude.

2 Build.

2 Physiological conditions (e.g. at rest, after exercise, standing, lying).

2 Sampling methods (e.g. with or without using tourniquet).

2 Storage and age of sample.

2 Container used, e.g. for blood sample, as well as anticoagulant.

2 Method of analysis.

Reference ranges (normal values) These are published for most measurable components of blood and other tissue and we have included the normal ranges for most blood and CSF analytes at the end of the book.

What makes a test useful?

A really good test, and one which would make us appear to be outstanding doctors, would be one which would always be positive in the presence of a disease and would be totally specific for that disease alone;

such a test would never be positive in patients who did not have the disorder. What we mean is that what we are looking for are sensitive tests that are specific for a given disease. Sadly, most tests are neither 100% sensitive nor 100% specific but some do come very close.

How to use tests and the laboratory Rather than request tests in a shotgun or knee-jerk fashion, where every box on a request form is ticked, it is far better to use the laboratory selectively. Even with the major advances in automation where tests are batched and are cheaper, the hospital budget is finite and sloppy requesting should be discouraged.

Outline your differential diagnoses: what are the likeliest diseases given the patient’s history, examination findings and population the patient comes from?

Decide which test(s) will help you make the diagnosis: request these and review the diagnosis in the light of the test results. Review the patient and arrange further investigations as necessary.

xxii The downside of tests It is important to remember that tests may often give ‘normal’ results even in the presence of disease. For example, a normal ECG in the presence of chest pain does not exclude the occurrence of myocardial infarction with 100% certainty. Conversely, the presence of an abnormality does not necessarily imply that a disease is present. This, of course, is where clinical experience comes into its own—the more experienced clinician will be able to balance the likelihood of disease with the results available even if some of the test results give unexpected answers.

–  –  –



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