A, Admit to: Indicate ward where pt is being admitted and attending physician (e.g., coronary care unit, Dr. Smith’s service).
B, Because: Indicate admitting dx (e.g., chest pain).
C, Condition: Specify pt’s general condition (stable, fair, poor, critical).
Code status: Specify DNR, full code, CMO.
Consults:
D, Diet: Specify whether regular, clear liquids, NAS, ADA, low cholesterol, other.
DVT prophylaxis:
A, Allergies: Indicate medications (including OTC medications) and specific food products to which the pt has experienced an allergic reaction.
Activity: Specify bed rest, ad lib, bathroom privileges.
V, Vital signs: Specify frequency (e.g., qid, q4h); also indicate any special nursing orders (e.g., VS and neurologic signs q2h × 24h, then q4h if stable).
I, IV fluids: Specify any IV solutions and rate of infusion.
D, Diagnostic tests: Specify laboratory tests, x-rays, ECG, special tests.
Drugs: Indicate medication, dose, frequency, special restrictions (e.g., atenolol 50 mg PO qd; if HR <50 bpm, hold atenolol and notify house).
2. Lab Shorthand Notation
See Figure 1-1.
3. Dictating the H&P
1. VS: BP, pulse, respirations, temperature.
2. General description: The pt is a (age, sex) who looks her stated age, is pleasant, appears to be well nourished, and seems in a good state of health.
3. Skin: The skin is warm and dry; turgor is adequate; color is nl. No icterus, purpura, rash, or unusual pigmentation is noted. Hair is nl in appearance, distribution, and texture.
4. Lymph nodes: There is no cervical, supraclavicular, axillary, epitrochlear, or inguinal adenopathy.
5. HEENT:
a. Head: It is normocephalic and atraumatic; no lesions are noted.
b. Eyes: Cornea is without lesions, conjunctiva is clear, sclera is white. Pupils are equal, measuring approximately 3 mm in diameter, round, and reactive to light and accommodation. Extraocular movements are within nl limits without any nystagmus or strabismus. Fundi appear benign. Disks are well delineated. There are no hemorrhages or exudates. Visual acuity is 20/20 bilaterally, and visual fields are within nl limits.
c. Ears: Ears are nl in appearance. Auditory canal appears clean and without lesions. The tympanic membranes are intact. Hearing is adequate.
d. Nose: Septum appears to be within nl limits and without deviation. Nasal mucosa appears pink and without any abnl discharge. No nasal polyps or other lesions are noted. Frontal and maxillary sinuses are nontender.
e. Mouth and throat: Lips are without cyanosis or pallor. Buccal mucosa is nl in appearance. Teeth appear to be in good condition. Tongue shows no lesions or tremor. Pharyngeal mucosa is pink and does not reveal any lesions, exudates, erythema, or evidence of inflammation. Gag reflex is intact.
6. Neck: Neck is supple. Full range of motion is present. There is no evidence of tracheal deviation, JVD, or lymphadenopathy. Carotid pulses are 2+, equal bilaterally, and without bruits. Carotid upstroke is within nl limits. Thyroid gland is nl in size; its palpation does not reveal any nodules or masses.
7. Back: Spinal curvature is nl; no scoliosis, kyphosis, or tenderness is present. Full range of motion is present.
8. Chest: Thorax is symmetric. Full expansion is noted bilaterally. Anterior-posterior diameter is within nl limits.
FIGURE 1-1 Lab shorthand notation.
9. Lungs: Fremitus is equal bilaterally. Lung fields are resonant throughout. Breath sounds and voice sounds are nl. There are no rales or rhonchi.
10. Heart: Palpation reveals no heaves or thrills. The PMI is medial to the midclavicular line, fourth intercostal space. Auscultation reveals S1, S2 of nl intensity. There are no S3, S4, rubs, clicks, or other abnl heart sounds. Heart rate is approximately 70 bpm and rhythm is regular.
11. Breasts (female pt): Breasts are symmetric and have a nl contour. Skin is of nl color and appearance; there is no edema, ulceration, or erythema. Nipples are of nl size and shape; there is no nipple retraction, ulceration, or discharge. Palpation does not reveal any tenderness or masses.
12. Abdomen: Abdomen is of nl size and contour. No capillary dilatations, skin lesions, or surgical scars are noted. Auscultation reveals normoactive bowel sounds and no abdominal bruits. Palpation reveals no abdominal tenderness, guarding, or masses. The liver edge is felt approximately 1 inch below the right costal margin; it is firm, sharp, and smooth. The liver percusses to approximately 8 to 10 cm in total span. The spleen is not palpable.
13. Rectal examination: Rectal examination reveals no external anal lesions. Sphincter tone is nl. There are no internal or external hemorrhoids. Rectal mucosa appears nl, and no nodules or masses are present. Stool is brown and (−) for occult blood. Male pt: Prostate is nl in size, no nodules.
14. Genitalia: Inspection reveals nl distribution of pubic hair. Female pt: Clitoris and labia are without lesions. Internal examination with speculum reveals nl vaginal wall. The cervical os is well visualized. No lesions or discharges are noted. A specimen was obtained for cervical cytology. Bimanual examination reveals no cervical tenderness or masses. Uterus and ovaries are nontender and of nl size.
15. Inguinal area: No lymphadenopathy is noted. Femoral pulses are 2+ and equal bilaterally. Auscultation reveals no femoral bruits.
16. Extremities: There is no clubbing, cyanosis, or edema. Brachial, radial, popliteal, dorsalis pedis, and posterior tibialis pulses are 2+ and equal bilaterally. Musculoskeletal examination reveals no joint deformities and full range of motion. No bone, joint, or muscle tenderness is noted.
17. Neurologic: Pt is alert and oriented to time, person, and place. Cranial nerves II to XII are within nl limits. Speech, memory, and expression are within nl limits. Muscle strength is 5/5 in both upper and lower extremities. No muscle atrophy or involuntary movement is noted. Testing of cerebellar function reveals nl gait, (−) Romberg test result, and good coordination in finger-to-nose, heel-to-shin, and alternate motion testing. Sensory is intact to light touch, pain, and vibratory stimuli. No focal motor or sensory deficits are present. Deep tendon reflexes are 2+ and equal bilaterally.
4. Progress (SOAP) Note
S, Subjective: observations, pt complaints.
O, Objective: description of physical findings and recording of laboratory, x-ray, or ECG data.
A, Assessment: analysis of data and tentative dx.
P, Plan: diagnostic studies and therapeutic regimen.
5. Consult Note
Date/time
Reason for consult
HPI
Current medications
Physical exam
Impression
Recommendations6. Discharge Summary
The discharge summary should contain only essential information about the investigation and Rx of the pt’s illness. It should briefly describe the following:
Why the pt entered the hospital: a brief statement of the CC, admission dx, and HPI.
The pertinent laboratory, x-ray, and physical findings; (−) findings may be as pertinent as (+) findings.
The medical or surgical Rx, including the pt’s response, any complications, and consultations; a rationale for what was or was not done.
The pt’s condition when discharged (ambulation, self-care, ability to work).
Instructions given on continuing care, such as medication by name and specific dosage, diet, type and amount of physical activity, other therapeutic measures, referrals, and appointments.7. Pronouncing Death While on Call
The legal criteria of death fall within state jurisdiction. One should become familiar with the accepted definition of death in one’s own state. When called to pronounce a pt dead, the following steps should be followed:
1. Identify the pt (examine hospital ID tag on the pt’s wrist).
2. Examine pt for:
a. Response to verbal or tactile stimuli (none)
b. Spontaneous respiration (none)
c. Heart sounds and pulses (absent)
d. Pupillary response (pupils fixed and dilated)
3. Document the time the pt was pronounced dead (legal time of death).
4. Notify attending physician (if not already done by the nursing staff) and inquire whether family requests autopsy. Notify the organ bank for possible organ donation, if this is consistent with your hospital’s policy.
5. Document findings in pt’s chart (e.g., “Called by charge nurse to pronounce Mr. John Smith dead. Pt examined, unresponsive to verbal or tactile stimuli, no spontaneous respiration noted, heart sounds not audible, pulses absent, pupils fixed and dilated. Pt pronounced dead at 11:10 pm. Attending notified. Next of kin to be contacted by attending.”) The attending will often not be available, and you will be asked to notify the next of kin.
a. Familiarize yourself with the pt’s medical hx and mode of death.
b. Identify yourself to the family in a humble and caring manner and inform them that their next of kin has expired. Inform them of the time that the pt was pronounced dead, and always try to comfort them that their relative died peacefully.
c. If it is not clear from the pt’s records, inquire whether the family requests an autopsy.
d. Ask the next of kin whether the family will be coming to the hospital to view the body before it is transported to the hospital morgue. Notify the charge nurse of their decision.
8. Discharge Against Medical Advice (AMA)
1. Discharge AMA, in which a pt chooses to leave the hospital before the treating physician recommends discharge, occurs in 2% of medical admissions.
2. Risk factors are h/o substance or EtOH abuse, lack of insurance, younger age, and male sex.
3. Strategies for preventing AMA discharges include proactively addressing substance abuse issues and recognizing and treating psychological factors. Motivational interviewing, which relies on the principle of pt-centered interviewing and use of nonjudgmental empathetic questioning, is an effective modality in lowering the risk of discharge AMA.
4. If prevention of discharge AMA is not successful, informed consent is a crucial element in managing an AMA discharge. An informed decision means that the decision has been made by the pt in consultation with the physician without being coerced and with a full understanding of the risks, benefits, and alternatives of the decision.
5. The evaluation of the pt being discharged AMA should include the following:
a. Does the pt understand and appreciate the admission dx, prognosis, and risks and benefits of leaving the hospital? It is important to document that the pt understands the information, terminology, and language (has adequate health literacy).
b. Is the pt aware of alternative Rxs outside of the hospital and associated risks and benefits?
c. Is the pt able to make and communicate his/her choice?
d. Can the pt articulate a reason for the choice that is consistent with his/her choice?
6. If a pt is deemed to be without decision-making capacity and has no surrogate, consultation with a psychiatrist may be helpful to keep the pt in the hospital against his/her will.
7. Managing an AMA discharge also includes ensuring that the discharge is as safe as possible under the circumstances and helping the pt follow up after discharge.
Reference
“I’m going home”: Discharges against medical advice. Mayo Clin Proc. 2009;84:255–260.
B
Evaluating the Labs
This section covers >150 labs. Each test is approached with the following format:
1. Lab test.
2. Normal (nl) range in adult pts.
3. Common abnormalities (e.g., [+] test result, ↑ or ↓ value).
4. Causes of abnl result.
The nl ranges may differ slightly, depending on the laboratory. The reader should be aware of the “nl range” of the particular laboratory performing the test. Every attempt has been made to present current laboratory test data with emphasis on practical considerations. Lab tests do not make diagnoses, physicians do. As such, any lab results should be integrated with the complete clinical picture and radiographic studies (if needed) to make a dx.
ACE Level
Acetone (Serum or Plasma)
Nl: (−)
↑: DKA, starvation, isopropanol ingestion.
Acetylcholine Receptor (ACHR) Antibody
Nl: <0.03 nmol/L.
↑: myasthenia gravis. Changes in AChR concentration correlate w/the clinical severity of myasthenia gravis after Rx and during Rx w/prednisone and immunosuppressants. False-(+) AChR Ab results may be found in pts w/Eaton-Lambert syndrome.
Acid Phosphatase (Serum)
Nl range: enzymatic, prostatic, 0-5.5 U/L; enzymatic, total, 2-12 U/L.
Activated Clotting Time (ACT)
Nl: This test is used to determine the dose of protamine sulfate to reverse the effect of heparin as an anticoagulant during angioplasty, cardiac surgery, and hemodialysis. The accepted goal during cardiopulmonary bypass surgery is usually 400 to 500 seconds.
Activated Partial Thromboplastin Time (APTT)
Adrenocorticotropic Hormone (ACTH)
Nl: 9-52 pg/mL.
↑: Addison’s disease, ectopic ACTH-producing tumors, congenital adrenal hyperplasia, Nelson’s syndrome, pituitary-dependent Cushing’s disease.
↓: secondary adrenocortical insufficiency, hypopituitarism, adrenal adenoma or adrenal carcinoma.
Alanine Aminotransferase (ALT, SGPT)
Nl range: 8-35 U/L (female); 10-40 U/L (male).
↑: liver disease (e.g., hepatitis, cirrhosis, Reye’s syndrome), EtOH abuse, drugs (e.g., acetaminophen, statins, NSAIDs, abx, anabolic steroids, narcotics, heparin, labetalol, amiodarone, chlorpromazine, phenytoin), hepatic congestion, infectious mononucleosis, liver mets, MI, myocarditis, severe muscle trauma, dermatomyositis or polymyositis, muscular dystrophy, malignant neoplasms, renal and pulmonary infarction, convulsions, eclampsia, dehydration (relative ↑), Chinese herbs.
↓: azotemia, advanced malnutrition, chronic renal dialysis, chronic alcoholic liver disease, metronidazole therapy.
Albumin (Serum)
Nl range: 4-6 g/dL.
↑: dehydration (relative ), IV alb infusion.
↓: liver disease, nephrotic syndrome, poor nutritional status, rapid IV hydration, protein-losing enteropathies (IBD), severe burns, neoplasia, chronic inflammatory diseases, pregnancy, prolonged immobilization, lymphomas, hypervitaminosis A, chronic GN.
Aldosterone (Plasma)
Nl: 3-16 ng/dL (adult supine); 7-30 ng/dL (adult upright); 200-800 ng/dL (adrenal vein).
↑: aldosterone-secreting adenoma, bilateral adrenal hyperplasia, secondary aldosteronism (diuretics, CHF, laxatives, nephritic syndrome, cirrhosis w/ascites, Bartter’s syndrome, pregnancy, starvation).
↓: Addison’s disease, renin deficiency, Turner’s syndrome, DM, isolated aldosterone deficiency, post–acute EtOH intoxication (hangover phase).
Alkaline Phosphatase (Serum)
Nl range: 30-120 U/L.
↑: biliary obstruction, cirrhosis (particularly PBC), liver disease (hepatitis, infiltrative liver diseases, fatty metamorphosis), Paget’s disease of bone, osteitis deformans, rickets, osteomalacia, hypervitaminosis D, hyperparathyroidism, hyperthyroidism, UC, bowel perforation, bone mets, healing fxs, bone neoplasms, acromegaly, infectious mononucleosis, CMV infections, sepsis, pulmonary infarction, hypernephroma, leukemia, myelofibrosis, MM, drugs (estrogens, alb, erythromycin and other abx, cholestasis-producing drugs [phenothiazines]), pregnancy, puberty, postmenopausal women.
↓: hypothyroidism, pernicious anemia, hypophosphatemia, hypervitaminosis D, malnutrition.
Alpha1-Fetoprotein (Serum)
Nl range: 0-20 ng/mL.
↑: hepatocellular carcinoma (usually values >1000 ng/mL), germinal neoplasms (testis, ovary, mediastinum, retroperitoneum), liver disease (alcoholic cirrhosis, acute hepatitis, chronic active hepatitis), fetal anencephaly, spina bifida, basal cell carcinoma, breast carcinoma, pancreatic carcinoma, gastric carcinoma, retinoblastoma, esophageal atresia.
ALT
Aluminum (Serum)
Nl range: 0-6 ng/mL.
↑: chronic renal failure on dialysis, parenteral nutrition, industrial exposure.
AMA
Ammonia (Serum)
Nl range: 15-45 μm/dL (adults); 29-70 μm/dL (children).
↑: hepatic failure, hepatic encephalopathy, Reye’s syndrome, portacaval shunt, drugs (diuretics, polymyxin B, methicillin).
↓: drugs (neomycin, lactulose), renal failure.
Amylase (Serum)
Nl range: 0-130 U/L.
↑: acute pancreatitis, macroamylasemia, salivary gland inflammation, mumps; pancreatic neoplasm, abscess, pseudocyst, ascites; perforated peptic ulcer; intestinal obstruction, intestinal infarction; acute cholecystitis, appendicitis, ruptured ectopic pregnancy, peritonitis, burns, DKA, renal insufficiency; drugs (morphine); carcinomatosis of lung, esophagus, ovary; acute ethanol ingestion; prostate tumors; after ERCP; bulimia, anorexia nervosa.
↓: advanced chronic pancreatitis, hepatic necrosis, cystic fibrosis.
Amylase, Urine
See Urine Amylase
ANA
ANCA
Angiotensin II
Nl: 10-60 pg/mL.
↑: HTN, CHF, cirrhosis, renin-secreting renal tumor, volume depletion.
↓: ACEIs, ARB drugs, primary aldosteronism, Cushing’s syndrome.
Angiotensin-Converting Enzyme (ACE Level)
Nl range: <40 nmol/mL/min.
↑: sarcoidosis, PBC, alcoholic liver disease, hyperthyroidism, hyperparathyroidism, DM, amyloidosis, MM, lung disease (asbestosis, silicosis, berylliosis, allergic alveolitis, coccidioidomycosis), Gaucher’s disease, leprosy.
↓: ACEI Rx.
Anion Gap
Nl range: 9-14 mEq/L.
↑: lactic acidosis, ketoacidosis (DKA, alcoholic starvation), uremia (chronic renal failure), ingestion of toxins (paraldehyde, methanol, salicylates, ethylene glycol), hyperosmolar nonketotic coma, abx (carbenicillin).
↓: hypoalbuminemia, severe hypermagnesemia, IgG myeloma, lithium toxicity, laboratory error (falsely ↓ Na+ or overestimation of HCO3− or chloride), hypercalcemia of parathyroid origin, abx (e.g., polymyxin).
Anticardiolipin Antibody (ACA)
Nl range: (−) Test includes detection of IgG, IgM, and IgA Ab to phospholipid, cardiolipin.
Present in: antiphospholipid Ab syndrome, chronic HCV infection.
Anticoagulant
Antidiuretic Hormone (ADH)
Nl: 295-300 mOsm/kg; 4-12 pg/mL.
↑: SIADH, antipsychotic meds, ectopic ADH from systemic neoplasm, GBS, CNS infections, brain tumors, nephrogenic diabetes insipidus.
↓: central diabetes insipidus, nephritic syndrome, psychogenic polydipsia, demeclocycline, lithium, phenytoin, EtOH.
Anti-DNA
Nl range: absent.
Anti-DS DNA
Nl: <25 U.
↑: SLE.
Anti–Glomerular Basement Antibody
Anti-HCV
Antimitochondrial Antibody (AMA)
Nl range: <1:20 titer.
↑: PBC (85%-95%), chronic active hepatitis (25%-30%), cryptogenic cirrhosis (25%-30%).
Antineutrophil Cytoplasmic Antibody (ANCA)
(+) test result:
• Cytoplasmic pattern (cANCA): (+) in Wegener’s granulomatosis.
• Perinuclear pattern (pANCA): (+) in IBD, PBC, PSC, autoimmune chronic active hepatitis, crescentic GN.
Antinuclear Antibody (ANA)
Nl range: <1:20 titer.
(+) test: SLE (more significant if titer >1:160), drugs (phenytoin, ethosuximide, primidone, methyldopa, hydralazine, carbamazepine, PCN, procainamide, chlorpromazine, griseofulvin, thiazides), chronic active hepatitis, age >60 years (particularly age >80 years), RA, scleroderma, MCTD, necrotizing vasculitis, Sjögren’s syndrome.
Antiphospholipid Antibody
Anti-RNP Antibody
Anti–SCL-70
Nl: absent.
↑: scleroderma.
Anti-SM (Anti-Smith) Antibody
Anti–Smooth Muscle Antibody
Antithrombin III
Nl range: 81%-120% of nl activity; 17-30 mg/dL.
↓: hereditary deficiency of antithrombin III, DIC, PE, cirrhosis, thrombolytic Rx, chronic liver failure, postsurgery, third trimester of pregnancy, OCPs, nephrotic syndrome, IV heparin >3 days, sepsis, acute leukemia, carcinoma, thrombophlebitis.
↑: warfarin Rx, after MI.
Apolipoprotein A-1 (APO A-1)
Nl: recommended > 120 mg/dL.
↑: familial hyperalphalipoproteinemia, statins, niacin, estrogens, weight loss, familial CETP deficiency.
↓: familial hypoalphalipoproteinemia, Tangier disease, diuretics, androgens, cigarette smoking, hepatocellular disorders, chronic renal failure, nephritic syndrome, coronary heart disease, cholestasis.
Apolipoprotein B (APO B)
Nl: desirable <100 mg/dL; high risk >120 mg/dL.
↑: high–saturated fat diet, high-cholesterol diet, hyperapobetalipoproteinemia, familial combined hyperlipidemia, anabolic steroids, diuretics, β-blockers, corticosteroids, progestins, diabetes, hypothyroidism, chronic renal failure, liver disease, Cushing’s syndrome, coronary heart disease.
Arterial Blood Gases (ABGS)
Nl range:
• PO2: 75-100 mm Hg
• PCO2: 35-45 mm Hg
• HCO3−: 24-28 mEq/L
• pH: 7.35-7.45
Abnl values: Refer to individual acid-base disturbances in Chapter 9.
Aspartate Aminotransferase (AST, SGOT)
Nl range: 0-35 U/L.
↑: liver disease (hepatitis, hemochromatosis, cirrhosis, Reye’s syndrome, Wilson’s disease), EtOH abuse, drugs (acetaminophen, statins, NSAIDs, ACEIs, heparin, labetalol, phenytoin, amiodarone, chlorpromazine), hepatic congestion, infectious mononucleosis, MI, myocarditis, severe muscle trauma, dermatomyositis and polymyositis, muscular dystrophy, malignant neoplasia, renal and pulmonary infarction, convulsions, eclampsia.
↓: uremia, vitamin B6 deficiency.
Basophil Count
Nl range: 0.4%-1% of total WBCs; 40-100/mm3.
↑: inflammatory processes, leukemia, PV, Hodgkin’s lymphoma, hemolytic anemia, after splenectomy, myeloid metaplasia, myxedema.
↓: stress, hypersensitivity reaction, steroids, pregnancy, hyperthyroidism.
Bicarbonate
Nl: 21-28 mEq/L (arterial); 22-29 mEq/L (venous).
↑: metabolic alkalosis, compensated respiratory acidosis, diuretics, corticosteroids, laxative abuse.
↓: metabolic acidosis, compensated respiratory alkalosis; acetazolamide, cyclosporine, cholestyramine, methanol or ethylene glycol poisoning.
Bile Acid Breath Test
Nl: The test determines the radioactivity of 14CO2 in breath samples at 2 and 4 hr.
• 2 hr after dose: 0.11 ± 0.14
• 4 hr after dose: 0.52 ± 0.09
↑: GI bacterial overgrowth, cimetidine.
Bilirubin, Direct (Conjugated Bilirubin)
Nl range: 0-0.2 mg/dL.
↑: hepatocellular disease, biliary obstruction, drug-induced cholestasis, hereditary disorders (Dubin-Johnson syndrome, Rotor’s syndrome), advanced neoplastic states.
Bilirubin, Indirect (Unconjugated Bilirubin)
Nl range: 0-1.0 mg/dL.
↑: hemolysis, liver disease (hepatitis, cirrhosis, neoplasm), hepatic congestion caused by CHF, hereditary disorders (Gilbert’s disease, Crigler-Najjar syndrome).
Bilirubin, Total
Nl range: 0-1.0 mg/dL.
↑: liver disease (hepatitis, cirrhosis, cholangitis, neoplasm, biliary obstruction, infectious mononucleosis), hereditary disorders (Gilbert’s disease, Dubin-Johnson syndrome), drugs (steroids, diphenylhydantoin, phenothiazines, PCN, erythromycin, clindamycin, captopril, amphotericin B, sulfonamides, azathioprine, isoniazid, 5-aminosalicylic acid, allopurinol, methyldopa, indomethacin, halothane, OCPs, procainamide, tolbutamide, labetalol), hemolysis, pulmonary embolism or infarct, hepatic congestion resulting from CHF.
Bleeding Time (Modified IVY Method)
Nl range: 2-9.5 minutes.
↑: thrombocytopenia, capillary wall abnormalities, Plt abnormalities (Bernard-Soulier disease, Glanzmann’s disease), drugs (ASA, warfarin, anti-inflammatory medications, streptokinase, urokinase, dextran, β-lactam abx, moxalactam), DIC, cirrhosis, uremia, myeloproliferative disorders, vWD.
Comments: The bleeding time test as a method to evaluate suspected hemostatic incompetence has been replaced in many laboratories by Plt function analysis (PFA-100 assay). The bleeding time test’s ability to predict excessive bleeding in clinical situations, such as surgery or invasive diagnostic procedures, is poor. It may play a limited residual role in the evaluation of suspected hereditary disorders of hemostasis.
BNP
BRCA1, BRCA2
Test involves the detection of carriers of mutations in the genes characterized by predisposition to breast and ovarian cancers. These mutations occur in about 1 in 300 to 500 women in the general population and in about 2% of Ashkenazi Jewish women. Women found to carry the mutation should undergo earlier and more intensive surveillance for breast cancer. Pre-test counseling should be provided before genetic testing. The U.S. Preventive Services Task Force recommends screening in the following:
1. Non-Ashkenazi women:
a. Two first-degree relatives w/breast or ovarian cancer (including one diagnosed ≤50 years of age).
b. ≥3 first- or second-degree relatives w/breast cancer.
c. Both breast cancer and ovarian cancer among first- and second-degree relatives.
d. A first-degree relative w/bilateral breast cancer.
e. ≥2 first- or second-degree relatives w/ovarian cancer.
f. A first- or second-degree relative w/both breast and ovarian cancer.
g. A male relative w/breast cancer.
2. Ashkenazi women:
a. Any first-degree relative w/breast or ovarian cancer.
b. 2 second-degree relatives on the same side of the family w/breast or ovarian cancer.
Breath Hydrogen Test
Nl: This test is for bacterial overgrowth H2 excretion; fasting: 4.6 ± 5.1; after lactulose: early ↑ <12. Lactulose usually results in a colonic response >30 minutes after ingestion.
↑: a high fasting breath H2 level and an ↑ of at least 12 ppm within 30 minutes after lactulose challenge indicate bacterial overgrowth in the small intestine. The ↑ must precede the colonic response.
False (+): accelerated gastric emptying, laxative use.
False (−): use of abx and pts who are non–hydrogen producers.
B-Type Natriuretic Peptide (BNP)
Nl range: up to 100 μg/L. Natriuretic peptides are secreted to regulate fluid volume, BP, and electrolyte balance. They have activity in the central and peripheral nervous system. In humans, the main source of circulatory BNP is the heart ventricles.
↑: heart failure. This test is useful to differentiate heart failure from COPD manifesting w/dyspnea. Levels are also ↑ in asymptomatic left ventricular dysfunction, arterial and pulmonary HTN, cardiac hypertrophy, valvular heart disease, arrhythmia, and ACS.
BUN
See Urea Nitrogen
C3
See Complement C3
C4
See Complement C4
Calcitonin (Serum)
Nl range: <100 pg/mL.
↑: medullary carcinoma of the thyroid (particularly if level >1500 pg/mL), carcinoma of the breast, apudomas, carcinoids, renal failure, thyroiditis.
Calcium (Serum)
Nl range: 8.8-10.3 mg/dL.
Captopril Stimulation Test
Nl: The test is performed by giving 25 mg captopril PO after an overnight fast. The pt should be seated during the test. After captopril, aldosterone <15 ng/dL, renin >2 ng angiotensin I/mL/hr.
Interpretation: In pts w/primary aldosteronism, plasma aldosterone remains high and PRA remains low after captopril.
Carbon Dioxide, Partial Pressure
Carbon Monoxide
Carboxyhemoglobin
Nl range: saturation of Hgb <2%; smokers <9% (coma, 50%; death, 80%).
↑: smoking, exposure to smoking, exposure to automobile exhaust fumes, malfunctioning gas-burning appliances.
Carcinoembryonic Antigen (CEA)
Nl range: 0-2.5 ng/mL (nonsmokers); 0-5 ng/mL (smokers).
↑: colorectal carcinomas, pancreatic carcinomas, and metastatic disease usually produce higher elevations (>20 ng/mL); carcinomas of the esophagus, stomach, small intestine, liver, breast, ovary, lung, and thyroid usually produce lesser elevations; benign conditions (smoking, IBD, hypothyroidism, cirrhosis, pancreatitis, infections) usually produce levels <10 ng/mL.
Cardio CRP
Carotene (Serum)
Nl range: 50-250 μg/dL.
↑: carotenemia, chronic nephritis, DM, hypothyroidism, nephrotic syndrome, hyperlipidemia.
↓: fat malabsorption, steatorrhea, pancreatic insufficiency, lack of carotenoids in diet, high fever, liver disease.
CBC
CD4+ T-Lymphocyte Count (CD4+ T Cells)
Calculated as total WBC × % lymphocytes × % lymphocytes stained w/CD4.
This test is used primarily to evaluate immune dysfunction in HIV infection. It is useful as a prognostic indicator and as a criterion for initiation of prophylaxis for several opportunistic infections that are sequelae of HIV infection. Progressive depletion of CD4+ T lymphocytes is associated w/ ↑ likelihood of clinical complications. Adolescents and adults w/HIV infection are classified as having AIDS if their CD4+ lymphocyte count is <200/μL or if their CD4+ T-lymphocyte percentage is <14%. HIV-infected pts whose CD4+ count is <200/μL and who acquire certain infectious diseases or malignant neoplasms are also classified as having AIDS. Corticosteroids ↓ CD4+ T-cell % and absolute number.
CEA
Ceruloplasmin (Serum)
Nl range: 20-35 mg/dL.
↑: pregnancy, estrogens, OCPs, neoplastic diseases (leukemias, Hodgkin’s lymphoma, carcinomas), inflammatory states, SLE, PBC, RA.
↓: Wilson’s disease (values often <10 mg/dL), nephrotic syndrome, advanced liver disease, malabsorption, TPN, Menkes’ syndrome.
Chlamydia Group Antibody Serologic Test
Test description: Acute and convalescent serum samples are drawn 2 to 4 weeks apart. A fourfold ↑ in titer between acute and convalescent sera is necessary for confirmation. A single titer >1:64 is considered indicative of infection.
Chloride (Serum)
Nl range: 95-105 mEq/L.
↑: dehydration, Na+ loss > chloride loss, respiratory alkalosis, excessive infusion of NS solution, cystic fibrosis, hyperparathyroidism, renal tubular disease, metabolic acidosis, prolonged diarrhea, acetazolamide administration, diabetes insipidus, ureterosigmoidostomy.
↓: vomiting, gastric suction, primary aldosteronism, CHF, SIADH, Addison’s disease, salt-losing nephritis, continuous infusion of D5W, thiazide diuretic administration, diaphoresis, diarrhea, burns, DKA.
Chloride (Sweat)
Nl: 0-40 mmol/L.
Borderline/indeterminate: 41-60 mmol/L.
Consistent with cystic fibrosis: >60 mmol/L.
Cholesterol, Low-Density Lipoprotein
Cholesterol, High-Density Lipoprotein
Cholesterol, Total
Nl range: Generally <200 mg/dL.
↑: primary hypercholesterolemia, biliary obstruction, DM, nephrotic syndrome, hypothyroidism, PBC, diet high in cholesterol and total and saturated fat, third trimester of pregnancy, drugs (steroids, phenothiazines, OCPs).
↓: use of lipid-lowering agents (statins, niacin, ezetimibe, cholestyramine, colesevelam); starvation, malabsorption, abetalipoproteinemia, hyperthyroidism; hepatic failure, carcinoma, infection, inflammation.
Chorionic Gonadotropins, Human (Serum)
Nl range, serum: <0.8 IU/L (female, premenopausal); <3.3 IU/L (female, postmenopausal); <0.7 IU/L (male).
↑: pregnancy, choriocarcinoma, gestational trophoblastic neoplasia (including molar gestations), placental site trophoblastic tumors; human antimouse antibodies (HAMA) can produce false serum assay for hCG.
The principal use of this test is to diagnose pregnancy. The concentration of hCG ↑ significantly during the initial 6 weeks of pregnancy. Peak values approaching 100,000 IU/L occur 60 to 70 days after implantation.
hCG levels generally double every 1 to 3 days. In pts w/concentration <2000 IU/L, an ↑ of serum hCG <66% after 2 days suggests spontaneous abortion or ruptured ectopic gestation.
Chymotrypsin
Nl: <10 μg/L.
↑: acute pancreatitis, chronic renal failure, PO enzyme preparations, gastric cancer, pancreatic cancer.
↓: chronic pancreatitis, late cystic fibrosis.
Circulating Anticoagulant (Antiphospholipid Antibody, Lupus Anticoagulant)
Nl: (−)
Detected in: SLE, drug-induced lupus, long-term phenothiazine Rx, MM, UC, RA, post partum, hemophilia, neoplasms, chronic inflammatory states, AIDS, nephrotic syndrome.
Note: The name is a misnomer because these pts are prone to hypercoagulability and thrombosis.
CK
See Creatine Kinase
Clonidine Suppression Test
Interpretation: Clonidine inhibits neurogenic catecholamine release and will cause a ↓ in plasma norepinephrine into the reference interval in hypertensive subjects w/o pheochromocytoma. The test is performed by giving 4.3 μg clonidine/kg PO after an overnight fast. Norepinephrine is measured at 3 hr. The result should be within established reference range and ↓ to <50% of baseline concentration. Lack of ↓ in norepinephrine suggests pheochromocytoma.
Clostridium Difficile Toxin Assay (Stool)
Nl: (−)
Detected in: abx-associated diarrhea and pseudomembranous colitis.
CO
Coagulation Factors
Factor reference ranges:
• V: >10%
• VII: >10%
• VIII: 50%-170%
• IX: 60%-136%
• X: >10%
• XI: 50%-150%
• XII: >30%
Figure 1-2 illustrates the blood coagulation pathways.
FIGURE 1-2 Coagulation cascade. Fibrin clot formation results from the generation of thrombin, which depends on the sequential interaction of proenzymes and activated coagulation factors in the intrinsic, extrinsic, and common pathways of coagulation. (From Noble J [ed]: Primary Care Medicine, 3rd ed. St. Louis, Mosby, 2001.)
Cold Agglutinins Titer
Nl range: <1:32.
↑: primary atypical pneumonia (Mycoplasma pneumonia), infectious mononucleosis, CMV infection, others (hepatic cirrhosis, acquired hemolytic anemia, frostbite, MM, lymphoma, malaria).
Complement (C3, C4)
Nl range:
• C3: 70-160 mg/dL
• C4: 20-40 mg/dL
Abnl values:
• ↓ C3: active SLE, immune complex disease, AGN, inborn C3 deficiency, membranoproliferative GN, infective endocarditis, serum sickness, autoimmune-type chronic active hepatitis.
• ↓ C4: immune complex disease, active SLE, infective endocarditis, inborn C4 deficiency, hereditary angioedema, hypergammaglobulinemic states, cryoglobulinemic vasculitis.
Complete Blood Count (CBC)
WBCs: 3200-9800/mm3
RBCs: 4.3-5.9 106/mm3 (male); 3.5-5.0 106/mm3 (female)
Hgb: 13.6-17.7 g/dL (male); 12-15 g/dL (female)
Hct: 39%-49% (male); 33%-43% (female)
MCV: 76-100 μm3
MCH: 27-33 pg
MCHC: 33-37 g/dL
RDW: 11.5%-14.5%
Plt count: 130-400 × 103/mm3
Diff: 2-6 bands (early mature neutrophils); 60-70 segs (mature neutrophils); 1-4 eosinophils; 0-1 basophils; 2-8 monocytes; 25-40 lymphocytes
Conjugated Bilirubin
Coombs, Direct (Antiglobulin Test, Direct, DAT)
Nl: (−)
(+): AIHA, erythroblastosis fetalis, transfusion reactions, drugs (methyldopa, PCNs, tetracycline, sulfonamides, levodopa, cephalosporins, quinidine, insulin).
Coombs, Indirect
Nl: (−)
(+): acquired hemolytic anemia, incompatible crossmatched blood, anti-Rh antibodies, drugs (methyldopa, mefenamic acid, levodopa).
Copper (Serum)
Nl range: 70-140 μg/dL.
↓: Wilson’s disease, malabsorption, malnutrition, nephrosis, TPN, acute leukemia in remission.
↑: aplastic anemia, biliary cirrhosis, SLE, hemochromatosis, hyperthyroidism, hypothyroidism, infection, iron deficiency anemia, leukemia, lymphoma, OCPs, pernicious anemia, RA.
Corticotropin-Releasing Hormone (CRH) Stimulation Test
Nl: A dose of 0.5 mg of dexamethasone is given every 6 hr for 2 days; 2 hr after the last dose, 1 μg/kg CRH is given IV. Samples are drawn after 15 minutes. There is normally a twofold to fourfold ↑ in mean baseline concentration of ACTH or cortisol. Cortisol >1.4 μg/L is virtually 100% specific and 100% diagnostic.
Nl or exaggerated response: pituitary Cushing’s disease.
Buy Membership for Internal Medicine Category to continue reading. Learn more here
