Diagnosis 6 (lab investigations) final

Laboratory investigations
Ali Fahd Fadel
BDS, MSc, IPCD, TQMHC, PhD
Lecturer of Diagnostic Science & Oral and Maxillofacial Radiology
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Laboratory tests
•Hemogram
•Hemostasis
•Diabetes Mellitus
•Blood chemistry
•Biopsy
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Laboratory tests
•Hemogram
•Hemostasis
•Blood chemistry
•Biopsy
4

Hemogram: complete blood count
CBC
I. RBC: Red blood cell count
II. Hb: Hemoglobin concentration
III. WBC: White blood cell count
IV. Platelet count
V. ESR: Erythrocyte sedimentation
rate
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Why CBC
1. Some blood diseases show oral
manifestations (anemia – leukemia)
2. Some blood diseases require precaution
during treatment (bleeding)
3. Identify systemic response of patient to
oral infection
4. Specific changes indicate infectious,
immunologic and malignant diseases
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I- RBCs
A)Count
B) Morphology
C) Indices
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A) RBCs count
• Normal
• Males 5.5 + or – 1 million
• Females 4.8 + or – 1 million
• Increased: Polycythemia
• Decreased: Anemia or Erythrocytopenia
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Decreased count
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B) Morphology
• Size (normal: 6.7 – 7.9 microns)
• Microcytes (less than……. )
• Macrocytes (more than…..)
• Megalocytes (more than 12)
• Schistocytes (less than 3)
• Shape (normal: biconcave discs)
• Not normal: Sickle cells
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C) RBCs Indices
• Hematocrit value (packed cell volume PCV)
• Volume of packed red cells relative to total blood volume
• Mean corpuscular volume (MCV)
• PCV X 10 / RBCs number
• Mean corpuscular hemoglobin (MCH)
• Hb concentration X 10 / RBCs number
• Mean corpuscular hemoglobin concentration (MCHC)
• Hb concentration X 100 / Hematocrit
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II- Hemoglobin concentration
•Normal
•Males
•Females
15 + or – 2.5 mg/dl
14 + or – 2.5 mg/dl
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III WBC
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Normal adults: 4000 – 11000/mm3
• Leukocytosis
• Physiologic
• Exercise – Temperature - Stress
• Pathologic
• Infection – Renal failure - Corticosteroids
• Leukopenia
• Production
• Bone marrow metastases
• Destruction
• Autoimmune
• HIV
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Disorders
• Neutropenia: B12 deficiency – Bone marrow depression (irradiation)
• Neutrophilia: Acute bacterial infection – sterile inflammation (burn)
• Lymphocytopenia: Renal failure – Immunodeficiency (HIV)
• Lymphocytosis: Chronic infection – some viral infections (mumps)
• Eosinopenia: Typhoid
• Eosinophilia: Allergic disorders – Lymphomas and leukemia (types)
• Basophilia (rare): Chronic myelogenous leukemia
• Monocytopenia: Aplastic anemia
• Monocytosis: TB - Malaria
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V- Platelets
• Main function: hemostasis
• Normal count: 150000 to 500000
• Thrombocytopenia
• 20000 - 50000: Bleeding with trauma or surgery
• Less than 20000: Spontaneous bleeding
• Less than 5000: Profuse spontaneous hemorrhage may occur
• Causes: recurrent transfusions - idiopathic – B12 deficiency – Drug induced
• Thrombocytosis (abnormal function: bleeding)
• Polycythemia – idiopathic
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Erythrocyte sedimentation rate
• Indicating active disease but not its
nature (not specific)
• Used for monitoring disease and its
response to TTT
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Laboratory tests
•Hemogram
•Hemostasis
•Blood chemistry
•Biopsy
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• Blood vessel contraction and integrity
• Platelets: adhesion – aggregation – release phenomena
• The clotting cascade
• Fibrinolytic system
Hemostasis
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Hemostasis
Primary hemostasis (within minutes)
mediated by adequate number of
functioning platelets
Secondary hemostasis (over hours to days)
depends on normal levels of coagulation
factors
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Lab investigations
for hemostasis:
• Testing capillary function: Hess
(tourniquet test)
Cuff
applied
on arm
Raise pressure
between systolic
and diastolic
5
minutes
> 10
petechiae in
1 inch circle
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Lab investigations
for hemostasis:
(tourniquet test)
• Testing platelet function
• Count
• Function analyzer (PFA)
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Lab investigations
for hemostasis:
(tourniquet test)
• Count
• Bleeding time
Normal: 2 – 8 minutes
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Lab investigations
for hemostasis:
(tourniquet test)
• Count
• Bleeding time
• Clot retraction
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Lab investigations
for hemostasis:
(tourniquet test)
• Testing clotting factors
• Clotting time
• PTT and APTT (activated
thromboplastin time)
• One stage prothrombin time (PT)
• Factors assays
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
Primary test, neither specific nor sensitive
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
If
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
Normal is 1
If international normalized
ratio exceeds 3, no surgery
attempted
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
Normal is 1
Prolonged in anticoagulant – liver diseases
Not prolonged in hemophilia
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Lab investigations
for hemostasis:
(tourniquet test)
• Clotting time
• Factors assays
• Adding all factors except the tested
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When should I ask for lab = test for patients
with potential bleeding:
1. Excessive bleeding after surgery, with no clue: PT, aPTT, TT, PFA-100, platelet count
2. Aspirin therapy: PFA-100 - PT
3. Coumarin therapy: PT
4. Heparin therapy: aPTT
5. Liver disease: platelet count, PT
6. Chronic leukemia: platelet count
7. Malabsorption syndrome or long-term antibiotic therapy: PT
8. RENAL dialysis (heparin): aPTT
9. Vascular wall alteration: BT
10. Primary fibrinogenolysis (active plasmin in circulation) cancers (lung, prostate): TT
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Laboratory tests
•Hemogram
•Hemostasis
•Blood chemistry
•Biopsy
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Diabetes is a group of
metabolic disorder sharing
the common features of
hyperglycemia
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• Based on specific laboratory findings as well as presence of clinical signs
and symptoms (mainly polyphagia, polyuria, polydipsia or unexpected wait
loss)
• Diagnostic guidelines include testing of the fasting and non-fasting glucose
level, with restricted use of oral glucose tolerance test
• Urinary glucose analysis is NO longer used
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Blood glucose level
• Random (casual) plasma glucose: ≥200 mg/dl DM
• Fasting (8 hrs.) plasma glucose (FPG): < 110 N - <126 impaired - >126 DM
• Post-challenge plasma glucose (PCG): > 200 DM
2 hrs. after the administration of a standard 75g oral glucose load
• Postprandial glucose (PPG): < 140 N - <200 impaired - >200 DM
2 hrs. after the patient’s regular breakfast
+ve findings from any (2) tests on different days
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Glucose tolerance test
• Detection of the response of the pancreas to a measured oral or I.V.
dose of glucose (the ability of the body to utilize glucose in blood
circulation)
• American Diabetes Association -------- For routine diagnosis
• WHO ------------For those with impaired fasting glucose
• American Diabetes Association and WHO ------- Gestational Diabetes
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• 3 days of unrestricted (high
carbohydrate) diet + physical exercise
• 10-16 hrs of fasting (nothing except water)
• Fasting blood sample is taken
• A measured dose of glucose is
administrated either; orally (75gm) or I.V.
(0.5 mg glucose /kg body wt.
• Blood sample are taken at ½ hr intervals for
2-3 hrs, thus giving 5-7 samples (1/2, 1 hr, 2
hr, then 3 hr)
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PROCEDURE
Not for person with confirmed diabetics mellitus
No role in follow-up of diabetics.
Not be done in ill patients
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• In persons with symptoms of diabetes but no glycosuria
or hyperglycemia
• Persons with family history but no symptoms or
positive blood findings
• In persons with or without symptoms of diabetes mellitus
showing one abnormal blood findings
• In patients with neuropathies or retinopathies of
unknown origin
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• Detect border line patients
• Differentiate between DM and other
causes of high GL hyperthyroidism
• Time consuming (2-3 hrs)
• Expensive (5 readings)
• Exhausting for the patients
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Hyperglycemia in last 3 months
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Laboratory tests
•Hemogram
•Hemostasis
•Blood chemistry
•Biopsy
66

Laboratory tests
•Hemogram
•Hemostasis
•Blood chemistry
•Biopsy
70
Blood
chemistry
It gives important information
about how well a person’s kidneys,
liver, and other organs are working.
An abnormal amount of a
substance in the blood can be a sign
of disease or side effect of
treatment.
Blood chemistry studies are used to
help diagnose and monitor many
conditions before, during, and after
treatment.
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The liver
• Considered the kitchen of the body
• Participate in a lot of function
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Function
of
liver
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1. Alkaline phosphatase (ALP)
Increased levels of ALP are seen in patients with liver disease as:
• Bile duct obstruction {as ALP excreted normally in bile, obstruction
cause regurgitation into the blood}: Increased 10-time normal level
• Cirrhosis
• Liver cancer
Note:
• ALP is not specific for liver function, as it elevated to other condition
• High levels of ALP are considered normal in growing children, healing
fracture and pregnant women
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2. Serum transaminases (aminotransferases)
i- Alanine Aminotransferase (ALT) [SCOT]
ii- Aspartate Aminotransferase (AST) [SGPT]
iii- Gamma-glutamyltransferase (GGT)
3- Serum bilirubin
4- Serum proteins
5- Blood urea nitrogen (BUN)
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• As a part of preventive health checkup
• To diagnose liver diseases like viral hepatitis, alcoholic
hepatitis, autoimmune hepatitis or liver cirrhosis
• To monitor the efficacy of a therapy given for the treatment
of existing liver disease
• To monitor the health of liver when a patient is on
medicines with known harmful effects on liver
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why???
Importance
of LFT in
dentistry
1.As liver function important for synthesis and
conjugation of most clotting factors (bleeding
tendency)
2.Liver function abnormality due to viral
infective hepatitis may be dangerous to the
dentist and other patients
3.Drug prescribed, and local anesthesia
administered to the patients with liver disease
should be watched for hepatotoxic effect and
drug metabolism
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Why is
Kidney
function test
done?
To diagnose any suspected kidney disease in
patients with
○ Increased or decreased frequency of urination
○ Abnormal swelling around the eyes and body
○ Other symptoms
To monitor the efficacy of a therapy given for
treating a kidney disease
As a part of preventive health checkups
To screen people who are at risk of kidney
disease
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Kidney
function
test
(KFT)
Creatinine
Uric acid
Blood Urea Nitrogen (BUN)
BUN / Creatinine ratio
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Laboratory tests
•Hemogram
•Hemostasis
•Blood chemistry
•Biopsy
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Biopsy isa surgical procedure to
obtain tissuefroma living organismfor
itsmicroscopical examination, usually
done to reach a diagnosis
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▶ When carful examination failsto reach the diagnosis.
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▶ Differentiate between several lesions.
▶ Inflammatorychanges of unknown cause that persist for long periods
▶ Lesions failed to respond to therapy in a limited period of time.
▶ Lesion that interfere with local function.
▶ Bone lesions not specifically identified by clinical and radiographic
findings.
▶ Recognize precancerous lesions.
▶ Any lesion that has the characteristics of malignancy.
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▶ Differentiate between several lesions.
▶ Inflammatorychanges of unknown cause that persist for long periods
▶ Lesions failed to respond to therapy in a limited period of time.
▶ Lesion that interfere with local function.
▶ Bone lesions not specifically identified by clinical and radiographic
findings.
▶ Recognize precancerous lesions.
▶ Any lesion that has the characteristics of malignancy.
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1. Inform the patient what you are doing.
2
. T
ake data with the specimen as:
a) Patient demographic data: name, age, sex.
b) Data of biopsy: date of procedure, area of the biopsy.
c) Clinical data: a brief description of the clinical appearance of the lesion and the
associated symptoms, along with tentative clinical diagnosis.
3. Avoid: iodine-containing surface, antiseptics since they cause
permanent staining of certain tissue cells.
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▶Anesthesia
▶Block anesthesia is preferred to infiltration.
▶When blocks are not possible distant infiltration may be used
▶Never inject directly into the lesion
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▶Tissue Stabilization
▶Digital stabilization
▶Specialized retractors/forceps
▶Retraction sutures
▶Towel Clips.
▶ Avoid:crushing of the lesion with a tweezers.
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▶Hemostasis
▶Avoid: Suction devices should be avoided
▶Gauze compresses are usually adequate
▶Gauze wrapped low volume suction may be
used if needed
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Incisions
1
. Incisionsshouldbe made withsharp multiple scalpels to avoid tearing.
2. Shouldextend beyond the suspected depth (deepened) untilthe
base of the lesion.
3. Sufficient tissue shouldbe removed.
4. Select the worstlookingarea to biopsy
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5.Should include clinical normal tissues for comparison (start from normal
to abnormal).
6.More than one specimen may be needed to represent large lesions.
7.Margins should include 2 to 3mm of normal appearing tissue if the lesion is
thought to be benign.
8. 5mm or more may be necessary with lesions that appear malignant,
vascular, pigmented, or have diffuse borders.
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100
Avoid
▶ Cuttingfromdiseasedtonormaltissuesto
preventimplantationof diseasedtissues.
▶ Areasofnecrosis.
▶ Cuttinginhighlyvascularorangiomatous
lesions
.
▶ Cuttingintowellcapsulated lesions.
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▶ The specimen should be placed in a large
mouthed bottle to avoid distortion of the
lesion.
▶ The bottle should contain a suitable fixing
solution [10%formalin solution], the
specimen should be completely immersed.
▶ I
f the specimen isthin, place it upon a piece
of glazed paper and drop.
▶ special care should be undertaken to hold the specimen
gently at the periphery of the sample.
▶
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▶Biopsy Data Sheet
▶A biopsy data sheet should be completed and the
specimen immediately labeled. All pertinent history
and descriptions of the lesion must be conveyed.
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Characteristicsoflesionsthatraisethesuspicion
ofmalignancy
▶ Erythroplasia- lesion is totally red or has a speckled red appearance.
▶ Ulceration- lesion is ulcerated or presents as an ulcer.
▶ Duration- lesion has persisted for more than two weeks.
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Characteristicsoflesionsthatraisethesuspicion
ofmalignancy
▶ Growth rate-lesion exhibits rapid growth
▶ Bleeding- lesion bleeds on gentle manipulation
▶ Induration- lesion and surrounding tissue is firm to the touch
▶ Fixation- lesion feels attached to adjacent structures
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FNAB
• US guided
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Excisional biopsy
• Small lesions
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Types
Exfoliative
cytology
Punch
biopsy
Drill
biopsy
Aspiration
biopsy,
Incisional
biopsy
Excisional
biopsy
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Diagnosis 6 (lab investigations) final

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