Clin Diagnosis
Terms
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- Acquired Immunity
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- Cell Mediated
link between T-lymphs and phagocytic cells - humoral immunity
- antibody mediated
- Active vs. Passive Antibodies
-
- Active - formed by host; natural or artificial (vaccine_
- Passive - received from another source (natural transfer or artificial - plasma infusion; RhoGam) - IgG
-
- major Ig in normal serum
- can cross placenta
- able to activate complement
- adult levels by age 16 - IgM
-
- large in size and limited to intravascular areas
- produced early in response - IgA
-
- predominant in secretions - teras, aliva, colostrums, breast milk
- IgA helicobacter in the stomach - IgD
- - found on surface of B lymphs in associated with IgM
- IgE
-
- elevated in hypersensitivity reactions, allergies, and parasitic infx.
- boinds to mast cells and basophils - Type I hypersensitivity
-
- immediated
- IgE mediated - Type II hypersensitivity
- - cytotoxic / cell-mediated
- DAT
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- Direct Antiglobulin test
- tests for presence of antibody coating RBCs after hypersensitivity (II) has occurred
- lavender tube - Indirect Coomb's test
-
- used in crossmathching blood
- tests for Ab in the tranfused unit with specific Ag on patient's RBC
- red tube - Type III hypersensitivity
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- immune complex
- see decresae in C3, C4, and CH50 - Type IV hypersensitivity
- - delayed hypersensitivty
- Direct Immunofluoresence (DFA)
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- looking for Ag
- Ab is tagged with FITC (fluorescein isothiocyanate - Indirect Immunofluoresence (IFA)
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- looking for Ab
- ex - ANA, FTA-ABS - Radioimmunoassay
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- radioisotoes used to measure concentration
- extrememly sensitive and detects trace amounts of analyte )T4, T3, TSH, B-HCG)
* quantitative rather than qualitative - Latex agglutination
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- latex particles coated with specific Ag for the Ab to be detected
- monospot, strep screen - flocculation
-
- clumping of particles to form visible masses similar to agglutination
- ex: RPR - ANA
-
- antinuclear antibodies
- screen test for collagen, rheumatic, CT,
- SLE
- nl is negative <1:20 - homogenous pattern of ANA fluorescence
- - associated with SLE
- peripheral or rim pattern of ANA fluorescence
- - active SLE
- fine speckled pattern of ANA fluorescence
- - mixed, CT disease, Sjogren's, scleroderma
- discrete, speckled pattern of ANA fluorescence
- - CREST, Raynauds
- nucleolar pattern of ANA fluorescence
- sleroderma, polymyositis
- ENA
-
- extractable Nuclear Antigens
- anti-RNP, anti-SM, anti-SSA, anti-SSB, anti-Scl70 - ANCA
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- Antineutrophilic cytoplasmic antibodies
- associated with Wegner's granulomatosus, churg-Strauss - High Thyroid titer
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- Hashimoto's Disease
- Grave's Disease
- Thyroid Cancer - ASMA
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- Anti-Smooth Muscle Ab
- liver and bile duct autoimmune disease
- 20% intrinsic asthma patients - AMA
-
anti-mitochondrial Ab
- liver and bile duct autoimmune disease - APCA
-
Anti-Parietal Cell Antibody
- pernicious anemia and chronic gastric disease - Rheumatoid Factor
-
- correlates w/ severity of disease and presence of nodules
- + if >30 IU
- negative does NOT rule out RA
- RF is not specific for RA - ASO
- - diagnosis of prior NOT acute strep infection
- RPR
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Rapid Plasmin Ragin
- secondary and latent stages of syphilis
- titers 1:16 or greater are considered + for syphilis diansis
- will eventually become non-reactive with tx - FTA-ABS
-
- Fluorescent treponemal antibody absorption
- confirms diagnosis of syphilis
- detects antibody to Treponema pallidum
- SLE and pregnant patiens may yield false rxn - VDRL
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Veneral Disease Research Lab
- detects reaginAb in CSF to aid in diagnosis of tertiary syphilis - CEA
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- Tumor Marker
- Carcinoembryonic Ag - se en in colorectal, stomach, pancreatic, breast, lung, stomach, and hepatobiliary cancers
- not relaible screen for colorectal cancers b/c not all produce CEA - AFP
-
- alpha-fetoprotein
- testicular and hepatic cancers
- found in 90% of pts. with hepatomas
- not specific for hepatomas but levels > 500ng/ml are diagnositc for hepatomas
- also used to dx neural tube defects
- picked up 16-18 wks. gestation - B-HCG
-
- beta subunit of human chorionic gonadotropin
- trophoblastic tumors, hydatidform moles, breast, and testicular cancers
- pregnancy tests - PSA
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- Prostatic Specific Ag
- seen in prostate cancer and in BPH
- Nl<4 ng/ml
- If >4 and <10 then order a free PSA to assess risk of cancer - PAP
-
- Prostatic Acid Phosphatase
- less spcific than PSA
- predicted PSA = 0.12* galnd volume - CA-125
-
- increased in 80% w/ ovarian cancer
- used to screen high risk w/ strong family hx
- may be increased in endometriosis - CA 15-3, CA 27.29
- - used in breast cancer staging and monitoring treatment
- CA19-9
- - pancreatic and hepatobiliary cancers
- stool specimen collection
-
- 3 specimens collected every other day prior to administration of antibiotics or anti-diarrheal agents
- avoid use of mineral oil and bismuth
- wait 10 days after barium study to do O and P - Flotation
- - employs reagnest with higher specific gravities than eggs and cysts so parasites can float to top to be skimmed off
- Protozoa
- - amoeba, flagellates (mobile), sporozoans
- Helminths
- worms
- Protozoa-Amebae
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* Entamoeba histolytica (amebic dysentery)
- Entameba coli
- Endolimax nana
- Blastocystis hominis
- Iodamoeba butschii - Protozoa - Flagellates
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* Giardia Lamblia
- dientameoba fragilis
- trichomonas vaginalis
- trypanosoma cruzi (Chaga's)
- Leishmania donovani - Giardia Lamblia
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- Cyst, fecal-oral transmission 1-2 wks after ingestion
- Sx: diarrhea, foul-smelling stools, bloating, flatuence, weight loss
- both trophozite and cyst (infective form) forms
- seen in daycares
- "old man" cyst - Giardia Lamblia Dx and Tx
-
- Dx: O and P. Find cyst in solid / semi-solid stools or trophozoites in liquid stools.
- Giardia antigen - ELISA
- old man cyst on ova and parasite
- Tx: Flagyl (metroniazole). Metallic taste, antabuse rxn w/ ETOH. - Leishmania
-
- intermediate host is the sand fly
- infective stage: promastigote found in the gut of sand fly
- can cause granulomas - Protozoa - Sporozoans
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- Plasmodium vivax
- Plasmodium falciparum
- Plasmodium malariae
- Plasmodium ovale
- Toxoplasma gondii
- Pneumocystis carnii
- Cryptosporidium pavum - Malaria
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- caused by plasmodium species
- cyclic rupture of RBCs as result of parasite maturation causes classic symptoms of recurrent fever and chills at regular 2-3 day intervals
- often associated with hypoglycemia - Labs and Tx for Malaria
-
- Labs - Giemsa-stained thick and think smears
- Tx - Larium (mefloquine)--> porphylaxis.
- Peds get Malarone - Nematodes
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- roundworms
- alimentary tract is simple tube from mouth to anus
- 20-200,000 eggs daily
- adults can have oral hooks, teeth, or plates - Enterobium Vermicularis
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- pinworm
- most common helminth infx in US
- eggs hatch in small intestines
- deposit eggs at anus
- perianal puritis
-Tx: Vermox - Trichuris trichiura
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- whipworm
- can prolapse the rectum - Ascaris lumbricoides
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- round worm
- hand/mouth transmission
- dry, windy climates and eggs are swallowed
- Tx: Vermox, recheck O&P in 2 months after tx to check for clearance - S&S, diagnosis, and treatment of Ascaris lumbricoides
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- S&S - Loeffler's pneumonia - abdominal obstruction or malabsorption
- Dx: O&P, eosinophila on peripheral smear, larvae in sputum, CXR with perihilar infiltrates
- tx: Vermox - Loa Loa
- eyeworm
- flukes
-
- symmetrical, leaf-shaped, non-segmented
- no anal opening - regurgitate waste
(Lung fluke, liver fluke, blood fluke) - Pityriasis versicolor
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- Tinea versicolor
- distinguis from vitiligo - "mantle distribution" - Superficial mycoses and Woods Lamp
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- tinea capitis - bright gray or green
- tinea corporis - blue/green
- tinea versicolor - yellow/ green
- vitiligo - will not fluroesce and only shows reflected light - Sporotrichosis
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- sporothrix schenckii
- gardners and greenhouse workers
- frequently from punctures with splinters or thorns
- follows lymphatics
- necrotic ulcer eventually - Histoplasmosis
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- Histoplasma capsulatum
- bird/bat feces
- culture requires 4-6 weeks
- DNA probes provide ID in 1-3 wks.
- Histoplasma antigen detected by RIA in urine or serum sample for immunodeficient
- sputum only pos in 10-15%
- complement fixation antibodies (1:32 titers)
- 75-95% positive 6 weeks after exposure - Coccidioides immitis
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- inhaled spores
- Labs: WBC < 10,000, eosinophilia, elevated ESR - Cryptococcus neoformans
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- only pahthogenic fungus to form a capsule
- immunocompromised host
- Tests: India ink - cryptococcal antigen in blood or CSF, positive cultures - Blastomyces dermatidis (Gilchrist's Disease)
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- inhlaed or cutaneous to systemic
- no serologic skin test b/c cross reacts with Histoplasma
- specific fluorescently labeled Ab will react with histologic tissue sections - titer
-
- dilution of serum with the Ab
- four fold or greater rise compared to the acute titer = active infection
- used in serology - Epstein-Barr Virus
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- Human Herpes Virus 4
- incubation 4-8 weeks
- acute phase 1-3 weeks
- Labs: atypical lymhs, EBV serology
- Monospot - current infx, - EBV in Africa and China
-
- In Africa associated w/ Burkitt's Lymphoma
- In China associated w/ nasopharyngeal carcinoma
- lifelong EBV carries and can reactivate for chronic fatigue syndrome - EBV Serology
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- EBNA - first antigen to appear. Abs develop later.
- Anti-VCA develops in early infx
- IgM - 1-2 mo duration
- IgG - lifelong duration
- Anti-EBNA develops 3-6 weeks, lifelong duration
- anti-VCA and anti-EBNA = past infx
- anti-VCA and NOT anti-EBNA = recent infection - anti-EBNA
- - seen with EBV and remains for life and represents past infection
- CMV
-
- herpes family
- most common cause of blindness in HIV with CD4<100
- "owl's eyes" - Influenzae-RNA virus Labs
-
- proteinuria
- antibody titers acute and convalescent 10-14 days apart
- nasopharyngeal swab for viral culture - Viral Influenzae Treatment
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- avoid ASA (Reyes syndrome)
- Amantadine - type A effective
- Tamiflu
- Relenza - Influenzae Prevention
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- Vaccine
- Flumist - live, attenuated vaccine against A and B - Shingles
-
- varicella zoster
- dermatomal distribution
- Valtrex (Tx) - HIV testing
-
1. ELISA
2. Western Blot - confirms
3. IFA (Indirect Immunofluorescence Assay) - confirms + ELISA faster - Parvovirus
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- fifth disease
- slapped cheek, fever, doilie rash, arthralgias
- order parvovirus Ab IgG and IgM
- IgM may be positive 3 days after viremia occurs - Rubella Ab (German Measles)
-
- birth defects esp if contracted during first trimester
- If suspected in newborn order IgM Ab to confirm active infx.
- IgG only shows maternal transfer - Hepatitis B carrier
-
- anti-HBs antibody appears and increases during recovery and lasts lifelong
- when anti-HBs does not develop and HBS Ag persists, patient is a CARRIER - Hepatitis B serology
-
- Anti-HBC is in serum when symptoms begin
- No test for Anti-HBcIgG
- Core window - AntiHBcIgM - Hepatitis Carrier vs. Immunity
-
- Carrier has HBs antigen that persists
- Immune - Anti-HBs - Dx. Hepatits C
-
- Hepatitis C antibody
- Hep C by PCR (amplifies virus)
- RIBA-2 is a confirmatory test
* No vaccine - Hepatits D
- - can replicate only when Hep B is present
- cirrhosis and hepatocellular carcinoma
- - can be caused by Hep B and Hep C
- Autologous vs. Allogenic transfusion
-
- Autologous - blood donor and recipient are the same
- Allogenic - blood transfused to somebody other than the donor - ABO typing
- - Ag is the same as the blood type
- RhoGam
-
- tags red cells before mom has ability to produced the Abs.
- prevents Abs from attacking baby in 2nd pregnancy
- given within 72 hours of delivery of Rh positive baby - Hemolytic Disease of the Newborn
-
- Rh+ male and Rh- female
- If baby from 1st preg is Rh+ some of blood will cross into mom. mom makes anti-Rh Abs that will attack the red blood cells of the baby in the next pregnancy if it is Rh+ - Kleinhauer-Betke Test
-
- measuring fetal blood in maternal blood
- determine amount of RhoGam - One unit of blood
- = 450 ml
- shelf life of blood
- 35 days
- Packed RBCs - life span and affect on Hbg and Hct
-
- storage up to 42 days
- frozen up to 10 years
- 1 unit raises Hbg by 1gm/dl or hematocrit by 3% - crystalloid
- - normal saline only crystalloid compatible with packed RBCs
- Packed RBCs characteristics (4)
-
1. leukocyte poor
2. Frozen RBCs
3. Washed RBCs
4. Deglycerolized RBC - Platelet storage
-
- stored up to 5 days
- transfused platelet survives 3-5 days - cryoprecipitate
-
- better for Factor 8 deficiencies
- each bag exposes recipient to 10 donors - Crossmatching
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1. Major - donor RBCs/Patient Serum
2. Minor - patient RBCs/donor serum - BMP
-
- Basal Metabolic Profile, chem-7, sma-7
- K, Cl, Na, CO2, BUN, creatinine, glucose - LFT
-
- Liver Function Tests
- AST, ALT, bilirubin - azotemia
- Increased BUN
- rhabdomyolysis causes...
- Increased serum creatinine
- BUN:Creatinine >15:1
- pre-renal causes (hemorrhage, shock, trauma, sepsis, dehydration)
- Normal Range for Na
- 136-145 mEq/L
- Factors that Affect Na
-
1. Aldosterone - kid reaborb Na
2. Natiuretic Hormone - inc renal loss of Na
3. ADH - reabsorption of water - Hyponatremia
- - most common electrolyte disturbance in hospitalized pts. (b/c dilute with IV)
- Hyponatremia Tx
- - Never replenish >12mEq/day or risk pontine myelinolysis
- Hypernatremia - sx and causes
-
- thirst
- hyperreflexia
- C: burns, diabetes insipidous, hyperaldosteronism, Cushings, inc water loss - Normal K Range
- 3.5-5.0 mEq/L
- Factors that Affect K
-
1. ADH - promotes K secretion
2. Aldosterone - K secretion
3. INsulin and EP - promote cellular reuptake of K
4. ACE-I - inc K - Hyperkalemia EKG
-
- *peaked T waves
- wide QRS
- depressed STs
- V-fib - Hypochloremia vs. Hyperchloremia
-
-Hypo - tetany, metabolic alkalosis, resp acidosis
-Hyper - weakness, lethargy, met acidosis, eclampsia - Anion Gap
-
- Normal Range: 8-12 mEq/L
- Na - (Cl+CO2)
- used to classify metabolic acidosis and mixed acid-base disturbances - Hypomagnesium
-
- cardiac irritability
- inc cardiac dysrhythmias
- assocaiated with dec K and dec Ca - EKG of Hypermagnesium
-
- conduction slowing
- wide PR,QT,QRS intervals - Hypophosphatemia
-
- hyperparathyroidism
- inc Ca
- ETOH
- alkalosis - Hyperphosphatemia
-
- hypoparathyroidism
- renal failure
- dec Ca
- acidosis - primary cause of hypercalcemia
- hyperparathyroidism with malignancy being 2nd leading cause
- Hypocalcemia S&S
-
- tetany
- Chvostek's sign
- Trousseau's sign
- cardiac dysrhythmias - glucagon
- - causes glycogen to break down to increase the blood sugar
- insulin
- moves glucose from bloodstream to the cells to decrease blood sugar
- Diagnosing a Diabetic (BS levels)
-
- fasting BS >200 one time
- fasting BS>126 on 2 ocassions - Non-Ketotic Hyperosmolar Syndrome
-
- glucose 700-800 range and ketones are not increased
- Hbg A1C - marker or glucose over past 3 mo.
- C-peptide (see how well the pancreas is making its own insulin) - Hemoglobin A1C
-
- 5% corresponds to glucose of 90
- for every 1% inc, add 30 to glucose - Glucose Tolerance Test
- - persistent elevated 2 hour levels are abnormal
- Conjugated vs. Unconjugated bilirubin
- Spleen --> RBC broken down into Hbg --> heme --> broken down into bilirubin --> unconjugated goes to liver --> gets conjugated --> bile duct --> bowels (or kidney --> urine)
- unconjugated bilirubin and LFTs
-
- bound to albumin
- can cross BBB
- >15mg/dl in newborns require tx to avoid brain damage - Jaundiced Patients
-
- bilirubin >2.5
- dark urine
- light colored stools - Increased direct bilirubin causes
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-extra-hepatic dyfunction
-biliary obstruction
-cholestasis - Increased indirect bilirubin causes
-
- hepatocellular dysfunction
- hepatitis
- Gilbert's Disease - when AST (SGOT) levels are elevated
-
- AMI
- CHF
- hypotension
- liver disease
- Reye's syndrome
- pancreatitis - when AST levels are decreased
-
- severe diabetes w/ ketoacidosis
- liver disease
- chronic hemodialysis - Alkaline Phosphatase
-
- liver enzyme
- can be heat fractionated to identify source (bone, kidney, placental liver)
- if only elevated LF test then fractionate it
- sensitive marker for liver metastasis
- inc in active bone formation - GGT
-
- Gamma-Glutamyl Transferase
- no longer part lipid panel
- obstructive enzyme
- indicator ETOH use - Pre-Albumin
-
- 1/2 life only 2 days
- acute process indicator
- used to check malnutriion and hepatic dysfunction - Ammonia
-
- normally transfomed into urea - but in liver dysfunction it cannot be catabolized
- inc in neonates w/in 48 hrs. of birth - 1st Cardiac Marker in a MI
- Myoglobin
- Troponin
-
- inc w/ heart injury but not specific to MI
- Troponin-I and troponin-T
- 2-4 hrs. post MI
- elevated 9-14 days - Most commonly used cardiac marker
- Troponin-I
- CPK
-
- Creatinine phosphokinase
- cardiac enzyme/marker
- 3 enzymes CK-BB, CK-MM, CK-MB - CK-MB
-
- cardiac muscle; depends on muscle mass
- primarly used to dx AMI
- ordered every 8 hr x 3
- inc after cardiac surgery, pericarditis, myositis - Last Cardiac Marker
-
Lactic Dehydrogenase
-LDH1 - heart - BNP
-
-brain natriuretic peptid
- >100 = heart failure - HDL
-
-good chol
-transport
-Tangier's Disease - HDL deficient resulting in chol deposit in tissues - Amylase
-
- produced mainly in salivary glands and pancreas
- inc = pancreatic origin or salivary gland inflammation - Tumors that increase Amylase
-
1. serous ovarian tumors
2. lung carcinoma - Lipase
-
*follows clinical course of pancreatitis more closely than amylase
- found in pancreas