1. COMMON LEARNING ISSUES PBL TEST 1 2012

2. ALPHA FETOPROTEIN  USED AS A SCREENING MARKER INDICATING INCREASED RISK FOR BIRTH DEFECTS (NEURAL TUBE, BODY WALL, AND CHROMOSOMAL)  PRODUCED BY FETAL LIVER AND YOLK SAC IF THERE IS A BODY WALL DEFECT THE AFP WILL LEAK INTO AMNIOTIC FLUID AND IS PICKED UP BY MATERNAL SERUM  ALSO ASSOCIATED WITH TUMOR MARKERS, HEPATOMA, TERATOMA, HODGKINS, LYMPHOMA, AND RENAL CELL CARCINOMA

3. ALPHA-FETOPROTEIN  NORMAL FINDINGS < 40 ng/mL Child < 30 ng/mL Ranges vary by week of gestation normally detected at 10 weeks Peak levels at 16-18 weeks  DECREASED LEVELS: TRISOMY 21 FETAL WASTAGE  INCREASED LEVELS: NTD, ABDOMINAL WALL DEFECTS MULTIPLE FETUSES THREATENED ABORTION FETAL DISTRESS OF CONGENITAL ANOMALIES FETAL DEATH

4. ANTINUCLEAR ANTIBODY (ANA)  Used to diagnose systemic lupus erthematosus (SLE) and other autoimmune disease  ANA is a group of protein antibodies that react against cellular nuclear material  Normal findings negative at 1:40 dilution

5. ARTERIAL BLOOD GASES  Monitor patients on ventilators, monitor critically ill nonventilator patients, establish preoperative baseline parameters, and regulate electrolyte therapy  pH –log[H+] Acids normally found in blood: carbonic, dietary, lactic and ketoacids Elevated indicates alkalosis Decreased indicates acidosis

6. BLOOD GASES  PCO2 Measure of partial pressure of carbon dioxide in the blood Measure of ventilation 10% free floating in plasma, 90% carried by RBCs Respiratory component of acid-base determination Co2 and pH are inversely proportional

7. BLOOD GASES  HCO3- or CO2 content Measure of the metabolic component of the acid-base equilibrium Regulated by the kidney Directly proportional to pH In alkalosis kidneys excrete more into the urine to lower pH  PO2 Pressure of oxygen dissolved in plasma Indirect measure of O2 content Determines effectiveness of oxygen therapy Determines the force of oxygen to diffuse across the pulmonary alveoli membrane

8. BLOOD GASES  Oxygen saturation Percentage of hemoglobin saturated with oxygen As PO2 decreases so does saturation of hemoglobin  Oxygen content The amount of oxygen in the blood Nearly all of it is bound to hemoglobin  Base excess/deficit Amount of anions in the blood, bicarbonate being the largest Also hemoglobin, proteins, phosphates Negative base excess indicates acidosis, positive alkalosis

9. BLOOD GASES  Alveolar to arterial oxygen difference If gradient is abnormally high there is a problem in diffusing oxygen across the alveolar membrane (thickened or edematous) or unoxygenated blood is mixing with oxygenated Thick walls due to edema, fibrosis, and RDS Mixing occurs with septal defects, shunts or underventilated alveoli still being perfused

10. KAROTYPE  Study an individual’s chromosome makeup to determine chromosomal defects associated with disease or risk for developing disease  Congenital or acquired because of duplication, deletion, translocation, reciprocation, or genetic rearrangement  Performed by a banding technique, pairing similar chromosomes based on size, location of centromere, banding patterns  Congenital anomalies, growth and mental retardation, infertility, delayed puberty, hypogonadism, amenorrhea, ambiguous genitalia, CML, neoplasm recurrent miscarriage, turner, klinefelter, downs

11. CBC  Measures RBC  Hemoglobin  Hematocrit  RBC Indices  WBC count  Blood smear  Platelet count  Mean platelet volume

12. CBC  Mean corpuscular volume ( MCV) Average volume or size of a single RBC Divide hematocrit by total RBC count Large: folic acid or B12 deficiency Small: iron deficient anemia or thalassemia  RBC # circulating RBC Normal life span 120 days Lysed and extracted from circulation by spleen

13. CBC  Mean corpuscular hemoglobin Measure of average weight of hemoglobin within RBC  Mean corpuscular hemoglobin concentration Average concentration or % of hemoglobin within RBC  RBC distribution width Indicates variation of size of RBC Important in classifying anemias

14. CBC  Blood smear Information concerning drugs and diseases that affect RBCs and WBCs Examines RBC, platelet, and WBC  White count Neutrophils, basophils, eosinophils, monocytes, lymphocytes

15. CBC  Platelet count Number of platelets formed in bone marrow of megakaryocytes Adult/child 150,000-400,000 Newborn/ premature infant: 100,000-300,000 Infant 200,000-475,000  Mean platelet volume Measure volume of large number of platelets to evaluate platelet disorders especially thrombocytopenia

16. CREATININE, BLOOD . Normal Findings:  A. Elderly: Decrease in muscle mass may cause decreased values  B. Adult: Male: 0.6-1.2 mg/dL Female: 0.5-1.1 mg/dL  C. Adolescent: 0.5-1.0 mg/dL  D. Child: 0.3-0.7 mg/dL  E. Infant: 0.2-0.4 mg/dL  F. Newborn: 0.3-1.2 mg/dL  ---creatinine clearance  1. used to measure the GFR of the kidneys  2. Normal Findings:  A. Adult (<40 yrs): Male: 107-139 mL/min Female: 87:107 mL/min  B. Values decrease 6.5 mL/min/decade of life after age 20 yrs with decline in GFR  C. Newborn: 40-65 mL/min

17. CREATININE  Catabolic product of creatine phsophate used in skeletal muscle contraction, depends on muscle mass  Excreted by kidneys and is directely proportional to renal excretory function; serum levels should be constant  Used to diagnose impaired renal function  Unlike BUN it is minimally affected by hepatic function  Approximation of GFR  Suggest chronic disease

18. CREATININE  In chronically unstable patients acute changes in renal function can make real time evaluation of GFR difficult  Cystatin C may be used for chronic kidney disease  Clearance: amount of filtrate made Amount of blood to be filtered and ability of glomeruli to filter

19. ERYTHROCYTE SEDIMENTATION RATE  no-n-specific test used to detect illnesses associated with acute and chronic infection, inflammation, advanced neoplasm, and tissue necrosis or infarction  Measure rate at which RBC settle in saline solution or plasma per unity time  RBC will settle faster with illness  Male up to 15 mm/hr  Female up to 20 mm/hr  Child up to 10 mm/hr  New born 0-2 mm/hr

20. ESTROGEN FRACTION  Estradiol Serum (pg/mL)Urine mcg/ 24 hr Child <10<150-6 Adult male10-500-6 Adult female Follicular phase25-3500-13 Midcycle peak150-7504-14 Luteal phase30-4504-10 postmenopausal<200-4

21. ESTROGEN FRACTION estriolSerum (ng/mL)Urine mcg/ 24 hr Male, child, postmenopausal 1-11 Follicular phase0-14 Ovulatory phase13-54 Luteal phase8-60 1 st trimester<380-800 2 nd trimester38-140800-12,000 3 rd trimester31-4605000-12,000

22. ESTROGEN FRACTION Total estrogenserumUrine mcg/ 24hr Male or child4-25 Female not pregnant4-60 1 st trimester0-800 2 nd trimester800-5000 3 rd trimester5000-50,000

23. ESTROGEN FRACTION  Evaluate sexual maturity, menstrual problems, and fertility problems  Evaluate males with gynecomastia or feminization  In pregnancy it indicates feto-placental health or tumor marker  FSH and LH stimulate ovaries to make estradiol (E2) Peaks during ovulatory phase of menstrual cycle Menopausal status, sexual maturity, fertility problems, gynecomastia, feminization syndromes, and tumor mark for ovarian tumors

24. ESTROGEN FRACTION  E1 or estrone is major circulator after menopause  E3 (estriol) major estrogen in pregnant female assess placental function and fetal normality, produced by placenta from estrogen precursors rising values are good declining values mean fetoplacental deterioration, preeclampsia/eclampsia, diabetes mellitus, anencephaly, death, dysmaturity  Increased levels liver necrosis, adrenal tumor, hepatic cirrhosis, hyperthyroidism  Decreased: turners, failing pregnancy, hypothryoidism or pituitarism, stein- leventhal syndrome, menopause, anorexia nervosa

25. MATERNAL SCREEN TESTING  Potential birth defects or serious chromosomal/genetic abnormalities  Women over 35 for downs, NTD, or abdominal wall defects  Double test hCG and AFP  Triple AFP, hCG, and estriol  Quadruple AFP, hCG, inhibin A, and estriol  With trisomy 21 AFP levels are 25% lower than normal hCG 2x higher  Inhibin A just like hCG

26. PARTIAL THROMBOPLASTIN TIME (PTT)  Assess the intrinsic system and common pathway of clot formation and to monitor heparin therapy  First phase of reactions is intrinsic system: factor XII forms complex on subendothelial collagen  Extrinsic factors include thromboplastin  Prothrombin becomes thrombin converts fibrinogen to fibrin  Plasmin degenerates  Evaluates fibrinogen II (prothrombin, V, VIII, IX, X, XI, and XII  If any of these exist in inadequate quantities then PTT is prolonged

27. PTT  Vitamin K deficiency can prolong PTT II, IX, and X are dependent  Coag factors are made in the liver so hepatocellualr disease will prolong  Heparin inactivates prothrombin (II) no thromoplastin  Monitor heparin whose effects are short-lived if too much is given protamine sulfate can reverse

28. HCG  <5 for non-pregnant people, used to diagnose pregnancy, increases throughout pregnancy, can be detected as early as 10 days post conception  Secreted by placental trophoblast  Immunologic test: high risk of false positive  Beta subunit characteristic of hCG  Radioimmunoassay: blood test for beta  Radioreceptor assay performed in one hour reliable  Ectopic pregnangy, hydatiform mole, and choriocarcinoma can produce  Liver cancer cells as well

29. PROTHROMBIN TIME  Adequacy of extrinsic system and common pathway  Activation of factor X in the presence of factor V and phospholipid and calcium  Stimulates platelet aggregation and converst fibrinogen to fibrin in clot stabilization  Factors I (fibrinogen) II (prothrombin), V, VII, and X

30. PT  Hepatocellular liver disease (cirrhosis, hepatitis, neoplastic invasive processes) I, II, V, VII, IX, X  Obstructive biliary disease bile necessary for fat absorption decreases A,D,E and K are all fat soluble II, VII, IX, X all dependent on vitamin K, differentiate from liver disease because it responds to vitamin K  Coumarin ingestion (warfarin) interfere with vitamin K associated factors; effects long lasting, can be fixed by vitamin K

31. RHEUMATOID FACTOR  Negative <60 units/mL  Used in the diagnosis of RA  RA: morning stiffness for 6 weeks, pain in at least one joint, swelling in at least 1 joint, symmetric bilateral joint swelling, presence of subcutaneous nodules, radiographic changes  Abnormal IgG made in synovial joints  IgG and IgM along with fc attack abnormal IgG  Immune complexes are activated and joint destruction begins

32. RF  Tests mainly for identification of IgM  Must be found in greater than 1:80 dilution  SLE may also give false positive  Tuberculosis, chronic hepatitis, infectious mononucleosis and subacute bacterial endocarditis may give false reading  Does not disappear in remission

33. BUN  10-20 mg/dL adult  Child and infant 5-18 mg/dL  Newborn 3-12 mg/dL  Rough and indirect measurement of renal function and GFR also a measure of liver function  Amount of urea nitrogen in the blood  Urea is an end product of protein metabolism and digestion  Elevated bun or azotemia

34. BUN  Shock, dehydration, congestive heart failure, excessive protein catabolism  GI bleeding  If kidney disease is unilateral and other kidney can take on role then BUN won’t be affected  Ureteral and urethral obstruction  Liver disease decreased BUN  Can be normal if there is liver and kidney disease

35. AMNIOCENTESIS  Performed on women whose pregnancies are high risk (diabetic, obese, older)  Indicate fetal maturity, distress, risk for RDS, genetic and chromosomal abnormalities, sex, NTD  Lung maturity (lecithin and sphingomyelin ratio) lecithin is a major constituent of surfactant 2:1 indicates maturity; at 35 weeks rapidly increases

36. AMNIO  Phosphatidyglycerol (PG) small component of surfactant, produced by mature lung alveolar cells appear at 35 weeks  Lamellar body count: produce by type II pneumocytes, represent the storage of surfactant  Microviscosity: aggregates dependent on L/S ratio and degree of saturation of fatty acid side chains, high early decreases later

37. AMNIO  Rh isoimmunization: assess levels of bilirubin in amniotic fluid, indicates severity of hemolytic anermia in Rh-sensitized pregnancy higher bilirubin, lower fetal hemoglobin, early delivery or blood transfusion may be indicated  Anatomic abnormalities: increased AFP neural crest abnormality  Fetal distress: pale, straw colored fluid tinged with green, yellow indicates blood incompatibility, yellow-brown may be intrauterine death red is blood contamination

38. ECHOCARDIOGRAPHY  Normal findings: normal position, size, and movement of cardiac valves and heart muscle wall, normal directional flow of blood within the heart chambers  Performed to evaluate heart wall motion and detect valvular disease, evaluate heart during stress testing and identify and quantify pericardial fluid  Ultrasound procedure to evaluate structure and function of heart

39. ECHO  M-mode echocardiography recording of amplitude and rate of motion in real time  Two dimensional ultrasonic beam moved within one sector of the heart 3D gives better image of heart wall and valves  Color flow: direction and velocity of blood flow within heart and great vessels for valve function in regards to regurgitation  Septal defects, perfusion, valvular heart disease, prolapse, stenosis, subaortic stenosis, tumors, aneurysm  Perflutren (definity or optison) provides enhancement of borders

40. OXIMETRY  >95% is normal  Monitors arterial oxygen saturation in patients at risk for hypoxemia. Surgery, cardiac stress testing, mechanical ventilation, heavy sedation, lung function testing or trauma  Non-invasive measures home many hemoglobin have oxygen attached to them  Fetal oxygen saturation monitoring: if heart is in distress but saturation is fine you can avoid c-section, placed on cheek between 30 and 70%

41. EATING DISORDERS  Anorexia nervosa: refusal to maintain body weight (BMI below 17.5), afraid of appearing fat, frequently staving but in denial, lacking insight, brought in by family members, failure to make expected weight gain as child or adolescent, amenorrhea, loss of libido or potency in men, depressive mood, irritability, social withdrawal, insomnia, decreased libido, self-induced vomiting or purging, excessive exercise, use of diuretics or appetite supressants  Increased corticotropin releasing factor, cortisol, growth hormone, serotonin, decrease diurnal cortisol fluctuation, LH, FSH, TSH  Bradycardia, hypotension, arrhythmias, cardiomyopathy  Hypokalemia, hypochloremic metabolic alkalosis, increased BUN, edema  Dry skin dental carries, delayed gastric emptying, constipation, anemia, osteoporosis

42. FREMITUS  Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking. To detect use ball or ulnar surface of hand to optimize vibration in bones of hand. Repeat 99 or one one one  Is decreased or absent when the voice is soft or when the transmission of vibrations from larynx to chest is impeded.  Causes of faint fremitus: very thick chest walls, obstructed bronchus, COPD, fibrosis, pleural effusion, pneumothorax or infiltrating tumor

43. HYPER-RESONANCE  Very loud, lower pitch, longer duration  Generalized hyper-resonance may be heard over the hyper-inflated lungs of COPD or asthma, but it is not reliable  Unilateral hyper-resonance suggests a large pneumothorax or large air filled bulla in lung

44. GRAVIDA-PARA  Gravida = total number of pregnancies  Para = or outcomes of pregnancies Often after you will see notations F (full-term), P (premature), A (abortion), L (living child)

45. APGAR  Key assessment of newborn immediately after birth 5 components take at 1 and 5 minutes after birth based on 0,1, or 2, total score is 0- 10, five minute score of 8+ move on to full exam  1 minute score 8-10 normal, 5-7 some nervous system depression 0-4 severe depression requiring immediate resuscitation  5 minute score 8-10 normal, 0-7 high risk for subsequent central nervous system and other organ dysfunction

46. APGAR Clinical sign012 Heart rateabsent<100>100 Respiratory effort AbsentSlow and irregular Good, strong Muscle toneFlaccidSome flexion of arms and legs Active movement Reflex irritability No responseGrimaceCrying vigorously, sneeze or cough colorBlue/palePink body, blue extremities Pink all over

47. VITAL SIGNS  Doppler method detects arterial blood flow vibrations, converts them to systolic normal for males is 70 mmHg at birth 85 at 1 month and 90 at 6 months  Pulse is best found at femoral artery

48. VITAL SIGNS ageAverage heart rateRange Birth 0-214090-190 0-613080-180 6-1211575-155

49. VITAL SIGNS  Fever can raise respiratory rates by 10 respirations per minute for each degree centigrade of fever  Temperature rectal, oral and auditory canal (rectal in infants) Usually above 99 degrees until after 3 years May approach 101 in normal children in late afternoon after vigorous activity Above 100 <2-3 months may be a sign of a serious infetion  Respiratory rate 30-60 per minute Birth – 2 months >60/minute cutoff 2-12 months >50/ minute cutoff

50. VERTEX PRESENTATION  Presentation of any part of the fetal head during birth  Head/neck in flexion so chin is pushed against chest  May be different degrees of flexion

51. CONGENITAL ADRENAL HYPERPLASIA  Refers to disorders of adrenal steroid biosynthesis that result in glucocorticoid and mineralcorticoid deficiencies  Because of deficient cortisol biosynthesis, increases in ACTH occurs, inducing adrenal hyperplasia and overproduction of steroids that precede blockage of enzyme production  21-hydroxylase (CYP21) deficiency is the most common (95%)

52. CAH  Failure of CYP21 and 17 hydroxyprogesterone and progesterone to 11 deoxycortisol and 11 deoxycorticosterone respectively with deficient cortisol and aldosterone is to replace  Aim of treatment for class in 21 hydroxylase deficiency is to replace glucocorticoids and mineralcorticoids, suppress ACTH and androgen overproduction and allow for normal growth and sexual maturation in children

53. SOUTHERN BLOT  Used for identifying DNA sequences on gels  Produced when DNA on a nitrocellulose blot of an electrophoretic gel is hybridized with a DNA probe

54. BMP VS. CMP  BMP/Chem-7: Sodium Chloride Potassium CO 2 /Bicarbonate BUN Creatinine Glucose  CMP/Chem-12: Same as BMP plus: AST ALT Albumin Bilirubin Alkaline Phosphatase

55. SODIUM (NA)  Normally 125-145 mmol/l  Collect in red top tube  Increased: Diabetes inspidius, exessive sweating, Cushing’s syndrome  Decreased: Excess body water (CHF, renal failure, small cell lung cancer, brain disorders), hypothyroidism, vomiting, diarrhea, pancreatitis

56. CHLORIDE (CL)  Normally 97-107 mEq/L  Collect in tiger top tube  Increased: Diarrhea, hyperalimentation  Decreased: Vomiting, renal disease, diabetic ketoacidosis

57. POTASSIUM (K)  Normally 3.5-5 mEq/L  Collect in red or tiger top tube  Hemolysis may falsely elevate level  Increased: Renal failure, Addison’s disease, dehydration, ACE inhibitors, Spironolactone  Decreased: Diuretics, NG suctioning, vomiting, diarrhea, metabolic alkalosis

58. CARBON DIXOIDE (CO 2 )  Normally 23-29 mmol/L  Collect in tiger tube top; don’t expose to air  CO 2 excreted into blood as bicarbonate  Increased: COPD, severe vomiting  Decreased: Starvation, diabetic ketoacidosis, diarrhea, dehydration

59. BLOOD UREA NITROGEN  Normally 5-20 mg/dl  Collect in tiger top tube  Increased: Renal failure, CHF, aminoglycosides  Decreased: Starvation, liver failure  BUN:Creatinine >20 suggests dehydration  BUN:Creatinine >30 suggests GI bleed

60. CREATININE  Normally <1.1 mg/dl  Collect in tiger or red top tube  Measures blood flow through kidneys  Increased: Renal failure, false positive seen in diabetic ketoacidosis  Decreased: Muscle wasting, liver disease

61. GLUCOSE  Normally 80-140 mg/dl  Collect in red or tiger top tube  Slight increase normal with aging  Increased: DM, Cushing’s syndrome, pancreatitis, thiazide diuretics  Decreased: Liver disease, malnutrition, sepsis, endocrine tumors

62. AST/ALT  Aspartate Aminotransferase: Normally 7-42 IU/L Increased: Liver disease, muscle trauma, burns Decreased: Vitamin B6 deficiency, dialysis AST>ALT in alcoholic hepatitis  Alanine Aminotransferase: Normally 1-45 IU/L Increased: Liver disease, billary obstruction ALT>AST in viral hepatitis

63. ALBUMIN  Normally 3.5-5 g/dl  Collect in tiger top tube  Best lab test for measuring protein  Decreased: Malnutrition, nephrotic syndrome, alcoholic cirrhosis, inflammatory bowel disease, metastatic cancer, leukemia, Hodgkin’s disease

64. BILIRUBIN  Normally 0.3-1 mg/dl  Collect in tiger top tube  Increased: Liver damage, hemolysis, billary obstruction

65. ALKALINE PHOSPHATASE  Normally 25-160 IU/L  Collect in tiger top tube  Increased: Liver disease, billary obstruction, bone tumors, healing fracture, hyperparathyroidism, hyperthyroidism  Decreased: Malnutrition, excessive vitamin D intake, pernicious anemia, zinc deficiency

66. WHITE BLOOD COUNT  Normally 4500-11,000  Differential provides more clues to cause than overall count does  Increased: Infection, inflammation, leukemia  Decreased: Bone marrow failure, vitamin B12 deficiency

67. CAUSE OF INCREASED DIFFERENTIALS  Basophils: Leukemia, s/p spleenectomy  Eosnophils: Allergies, asthma, parasites  Lymphocytes: Viral infections, leukemia  Monocytes: Bacterial infections, protozoan infections, ulcerative colitis  Neutophils: Bacterial infection, noninfectious tissue damage, metabolic disorders

68. H & H  Hematocrit: ~40-50% (lower in women, higher in men)  The percentage of blood that is RBCs  Decreased with anemia and blood loss  Hemoglobin: ~12-16 g/dl (lower in women, higher in men)  Does not acurately reflect acute bleeding because plasma and RBC lost at same rate

69. COAGULATION STUDIES  Collect in blue top tube  PT: 11.5-13.5 second  INR: 0.8-1.4  Higher with mechanical heart valves or history of thromboembolitic disease or atrial fibrillation  INR is now the standard measure reported

70. CAUSES OF POSITIVE VALUES ON UA  Bilirubin: Jaundice, hepatitis, fecal contamination of sample  Blood: Stones, BPH, infection, Foley cath  Glucose: DM, pancreatitis, steroids  Ketones: Starvation, high fat diet, diabetic ketoacidosis, vomiting, diarrhea, asprin overdose

71. CAUSES OF POSITIVE VALUES ON UA  Leukoesterase: UTI Leukoesterase plus nitrates: 75% of UTI Neither LE or nitrates: 92% not UTI  Protein: Renal failure, CHF