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AGuideto InterpretingU&Es, LFTs,&TFTsand Communicating Findings SSC5 PAL Jo-Yin, Braydenh, Michael, Supervisors: Robyn Canham, Lachlan Dick SSC5OSCETeachingonInterpretingand CommunicatingInvestigationFindings Onlinetutorials Preparefordatainterpretation 2. ECG (17/1/23)10/1/23) OSCEstationsandgain 3. Bloods: ABG. FBC (24/1/23) confidenceincommunicating 4. Bloods: U&Es, TFTs, LFTs (31/1/23) testresultstopatients! MockOSCEs - 12/2/23 and 15/2/23 (G.13 MST Doorway 4) - 2-to-1 stations with individual feedback! KyiLae,Natalie,Elizabeth,Diana,Caroline,Sophie,Brayden,Georgia,Magil,Michael,Jo-Yin Aims&Objectives SystematicApproach CommonPresentations OSCESimulation EffectiveCommunication Learn how to effectively Develop a systematic Learn about common Gain familiarity with a data communicate U&Es, LFTs & appTFTs interpretations, abnorU&Es, LFTs, TFTss of interpretation OSCE station TFTs results to patients in an OSCE setting SessionOutline 1.Systematic 2.Common Approach Presentations 6.Q&A 3.*PracticeMCQs *At the end of the slides! 5.OSCEDemonstration 4.OSCEFormat SystematicApproachtoInterpretingU&Es 01 02 03 Urea, creatinine, eGFRPrevious eGFRs Electrolytes U&EsOverview What’sincluded Whycheck? ● Serum Creatinine ● Assess renal function ● eGFR ● Electrolyte disturbances ● Serum urea ● Suspected upper GI bleed ● Serum sodium ● Drug monitoring ● Serum potassium ○ ACE, ARBs, diuretics, DOACs, carbamazepine, lithium, digoxin Creatinine&eGFR Creatinine eGFR - Muscle metabolism Calculated based on creatinine and - Excreted entirely by kidney age, sex, race. - Proxy for kidney function ‘Normal’ ~100ml/min/1..73m² Limitations - extremes of bodytype, <18yrs. https://fadic.net/creatinine-clearance-calculator/ Urea HIGH - Protein waste product (uraemia) - Produced by liver - Excreted predominantly by kidney Renal dysfunction - Non-specific Dehydration (ADH regulation) Upper GI bleed (blood metabolised in the liver) Increased protein breakdown LOW (Non-pathological) Pregnancy Low-protein diets. https://www.news-medical.net/health/The-Urea-Cycle-Step-by-Step.aspxDon’t forget to ensure eGFR is accurate. Step1-AssessUrea,Creatinine&eGFR Is there evidence of kidney injury? I.e. is there a low eGFR? Raised creatinine +/- raised urea - suggestive of renal dysfunction Normal Range Urea ONLY raised - suggestive of non-renal Urea 2.0-7.0 mmol/L cause e.g. dehydration, GI bleed. Creatinine 55-120 umol/L eGFR >60 Step2-ComparetopreviousCreatinine/eGFR AKI vs CKD? AKI - rapid worsening of kidney function CKD - longstanding - diagnosed with blood tests 3 consider UCR months apart Urea:Creatinine Ratio High >100:1 Within normal Low <40:1 range Pre-renal AKI Post-renal AKI? Intra-renal AKI (most common) *i.e. normal U&Es and no proteinSources: Passmed CommonPresenation1 A 65-year old man with a history of hypertension is reviewed. As part of routine blood tests to monitor his renal function whilst taking ramipril the following blood tests are received: Urine dipstick shows mild proteinuria. What stage of CKD does this patient have? a. No CKD b. CKD stage 4 c. CKD stage 3 d. CKD stage 2 e. CKD stage 1 Source: Passmed Hyponatraemia - Many causes - Plasma osmolality - Requires patient hydration - Hydration status <135mmol/L status Sodium - ADH + Aldosterone N/V,headache,confusions, - May require further - Neurological symptoms seizures,reduces investigations. - Slow correction consciousness Hypernatraemia >145mmol/L Thirst,confusion,muscletwitching Dehydration Diabetes Insipidus Drugs Osmotic diuresis High salt intake Potassium Sev Mod Mild Normal Mild Sev >6.5 6.0-6.4 5.5-5.9 3.5-5.5 3.5-3.0 <3.0 Hyperkalaemia Hypokalaemia Arrhythmias,lethargy,muscleweakness Arrhythmias,tremor,muscle Reduced renal excretion - renal injury, weakness/cramps,constipation drugs, aldosterone insufficiency, systemic acidosis GI loss Excess K+ load Renal loss Release from intracellular fluid - Intracellular accumulation systemic acidosis, tissue breakdown DREAD & DIREParticularly consider clues from the history! Step3-AssessElectrolytes Disturbed electrolytes due to AKI/CKD? OR Disturbed electrolytes due to another reason? E.g. Drugs, Fluid status, Metabolic, Endocrine, Tissue damage, GI Normal Range Further investigations? Sodium 135-145 mmol/L Acute or Chronic (< or >48hrs onset)? Potassium 3.5-5.5 mmol/L Treatment TIP: if there is evidence of CKD you may want to request a bone profile. CommonPresentation2 What is the diagnosis? What is the most likely cause? a. Rhabdomyolysis b. Dehydration c. Bendroflumethiazide d. UTI Source: Passmed e. Myeloma CommonPresentation3 What is the diagnosis? Which medication should be stopped? a. Allopurinol b. Bisoprolol c. Furosemide d. Morphine e. Omeprazole Source: Passmed LIVERFUNCTIONTESTS(LFTs) Source: NIHR, Edinburghlabmed Why? - To investigate patients with suspected liver disease - To monitor patients with confirmed liver disease - To monitor the effects of potentially hepatotoxic medications Reference range (NHS Lothian) - ● Alanine transaminase (ALT) ALT - 10 - 50 U/L ● Aspartate aminotransferase (AST) ● Alkaline phosphatase (ALP) AST - 10 - 45 U/L ● Gamma-glutamyltransferase (GGT) ALP - 40 - 125 U/L GGT - Male 10 - 55 U/L; Female ● Bilirubin (total) 5 - 35 U/L ● Albumin Bilirubin (total) - 3 - 21 µmol/L Albumin - Adult: 36 - 47 g/L AST&ALT AST AST:ALT ratio Ratio of AST:ALT - Cytosolic and mitochondrial isoenzymes - Can be found in liver, heart, skeletal ● ALT>AST: chronic liver disease, viral hepatitis, ischaemic necrosis, toxic hepatitis muscle, kidneys, pancreas ● AST>ALT: >1 in established cirrhosis, >2 in alcoholic ALT liver disease - Cytosolic enzymes specific to liver Raised AST & ALT Marked increase (>1000): - Markers of hepatocellular injury ● Toxin-/drug-induced hepatitis - Hepatitis (viral, alcoholic, ischaemic) ● Acute viral hepatitis - Liver cirrhosis ● Ischaemic hepatitis - Drug / toxin-induced liver injury - Malignancy (hepatocellular carcinoma) ALP&GGT ALP GGT - biliary epithelial cells, bones, placenta, small - hepatocytes and also biliary epithelial cells intestine (fatty meals) - renal tubules, pancreas, lymphocytes, brain, - Commonest causes testes - Complete biliary obstruction - can be used to confirm source of raised ALP (malignancy, infection) - Particularly sensitive to effect of alcohol on liver - Extensive bone metastases - Hyperparathyroidism - Hepatocellular damage ALP with normal GGT - bone disease ALP and GGT - cholestasis GGT - alcohol excess Source: Bilirubin eclinpath a waste product of haemoglobin breakdown - Marker of severity in acute cholestatic and hepatocellular pathologies - Pre-hepatic, hepatocellular, cholestatic jaundice ● Unconjugated hyperbilirubinaemia: increased ‘indirect’ bilirubin ○ Haemolytic anemia, Gilbert’s syndrome ● Mixed hyperbilirubinaemia ○ Hepatocellular dysfunction (liver disease) ● Conjugated hyperbilirubinaemia: increased direct bilirubin (0 - 20 µmol/L) ○ Hepatocellular jaundice ○ cholestasis Bilirubin (total) - 3 - 21 µmol/L Bilirubin (direct) - 0 - 20 µmol/L Jaundice is usually absent until the bilirubin level exceeds 50 micromol/L. Albumin a non-specific marker of the synthetic function of the liver ● Decreased albumin production: malnutrition, severe liver disease ● Increased albumin loss: protein-losing enteropathies, nephrotic syndrome - A decrease in synthetic function indicates severe liver disease - Half life of 20 days SystematicApproachtoInterpretingLFTs 01 02 03 Lookattheoverall Assessbilirubin Assesssynthetic pattern function InterpretingLFTs 1. Determine the pattern of derangement of LFTs Cholestatic or hepatocellular: - ALT >10X & ALP <3X - Primarily hepatocellular - ALT <10X & ALP >3X - Primarily cholestatic - Mixed picture 2. Assess bilirubin 3. Assess synthetic function a. Albumin b. Coagulation screen? Source : Geekymedics Commonpresentation A 66-year-old man presents to the emergency department. He has been experiencing abdominal pain and fever for the last two days. He is currently very drowsy and unable to give a full history. On examination, he looks in pain and you can observe a distended abdomen and jaundiced sclera. Bilirubin 67 µmol/L(3 - 17) ALP 45 u/L (30 - 100) ALT 110 u/L (3 - 40) AST 240 u/L (0 - 35) γGT 99 u/L (8 - 60) Albumin 35 g/L (35 - 50) Source: Passmedicine Image: Teach Me Anatomy ThyroidFunctionTests SystematicApproachtoInterpretingTFTs 01 02 03 AsTSHs Free T4 (T4) AdAnti-TPO, TRAbGeeky Medics THYROIDFUNCTIONTESTS(TFTs) What does this include? ● TSH (0.4 – 4 mU/L) ● Free T4/T4 (9 – 25 pmol/L) ● Free T3 (3.5 – 7.8 nmol/L) Considerations: ● Free T3 is not considered as clinically relevant (thyroid releases T4 and T3 at 20:1 rate) ● T4 is converted to T3 peripherally = Better indicator of hormone levelGeeky Medics Step1-AssessTSH ● TSH = Thyroid Stimulating Hormone ● Hormone produced by pituitary ● Stimulates thyroid gland -> thyroxineGeeky Medics Step2-AssessT4 ● T4 = Thyroxine ● Produced by thyroid gland ● Leads to peripheral conversion to triiodothyronine (T3) T4 Increased T4 Decreased Tachycardia Lethargy Palpitations Poor concentration Heat intolerance Weight gain Sweating Cold intolerance Diarrhoea Constipation Fine tremor Hair loss Hyperactivity/Weight loss Dry skin Anxious/Irritability Bradycardia Difficulty sleeping Delayed/Slowed reflexesGeeky Medics Step3-AdditionalTests Anti-TPO = Hashimoto’s Disease (Hypothyroidism) Thyroid Receptor Antibody (TRAb) = Grave’s Disease (Hyperthyroidism)Case Example CommonPresentations:1 A 30-year old woman complains of progressive weight gain of 10kg in 1 year, fatigue, slight memory loss, slow speech, dry skin, constipation and cold intolerance Physical examination: BP 140/100, moderately obese and speaks slowly, has a puffy face, with pale, cool, dry and thick skin. The thyroid gland is slightly enlarged, firm, non-nodular, mobile and non-tender. Deep tendon reflex time is delayed Lab investigations: CBC/WBC normal. Serum T4 concentration is 3.8 pmol/L, serum TSH is 23.0 mU/L, and serum cholesterol is 255 mg/dl. What is the diagnosis? ● TSH (0.4 – 4 mU/L) ● Free T4/T4 (9 – 25 pmol/L) ● Free T3 (3.5 – 7.8 nmol/L)Geeky Medics CommonPresentations:PrimaryHypothyroidism ● Reduced thyroid hormone (T3/T4) secretion Lab Findings: from the thyroid / reduced ability to respond to TSH ● TSH - Increased ● Causes negative feedback on the pituitary ● T4 - Decreased and hypothalamus ● Leads to an increase in TRH, TSH and a decrease in T3 and T4 Aetiology: ● Autoimmune thyroiditis ● Iodine deficiency or excess ● Therapy with radioactive iodineCase Example CommonPresentations:2 A 22-year old woman complains of palpitations, nervousness, heat intolerance and amenorrhoea. Physical examination: Smooth goitre with soft bruit on neck palpation. Lid lag present. Heart rate is tachycardic (120 bpm). Lab investigations: CBC/WBC normal. Serum T4 concentration is 30 pmol/L and serum TSH is 0.2 mU/L. Additional testing reveals TRAb positive. What is the diagnosis? ● TSH (0.4 – 4 mU/L) ● Free T4/T4 (9 – 25 pmol/L) ● Free T3 (3.5 – 7.8 nmol/L)Geeky Medics CommonPresentations:PrimaryHyperthyroidism Lab Findings: ● Excess T3 and T4 produced by the thyroid ● Causes negative feedback on the pituitary ● TSH - Decreased and hypothalamus ● T4 - Increased ● Leads to a decrease in TRH, TSH and an increase in T3 and T4 Aetiology: ● Grave’s disease (TRAb positive) ● Toxic multinodular goitre ● Toxic adenomaGeeky Medics CommonPresentations:SubclinicalHyperthyroidism/ Hypothyroidism Subclinical Subclinical Hyperthyroidism Hypothyroidism ● Decreased TSH ● Increased TSH ● Normal T4 ● Normal T4Geeky Medics TFTOverview: DataInterpretationOSCEStations 2 minutes of reading time (results of investigation will likely only be provided once inside the station) 8 minutes to interpret the data and speak to the patient* Tests ability to interpret results as well as to communicate these to the patients simply and clearly AGeneral ApproachtoData Interpretation OSCEStationsIntroductions,confirmpatient(name,DoB),gainconsent,signpost Takeashort,focusedhistory(explorekeysymptoms) results! Ideas,concerns,expectations Checkpatient’spriorknowledge Explainthepurposeoftheinvestigation Chunk and check throughout! Describepositiveandnegativefindings Explainwhattheabnormalresultsindicate,includingdifferentials Nextsteps:furtherinvestigationsand/ormanagement Summarise,addressquestionsandconcerns,thankpatient OSCE Demonstration OSCEDemonstration Scenario CandidateInstructions You are a 4th year medical Interpret the patient’s blood student at the GP. A test results using a structured 47-year-old woman has come approach. to discuss her recent routine blood test results. Take a focused history and explain the findings and the likely diagnosis. Explain the relevant investigations and management plan. BMI 33 kg/m2 Bilirubin 12 µmol/L (3 - 17) ALP 88 u/L (30 - 100) AST 74 u/L (3 - 40) ALT 103 u/L (3 - 40) LFT γGT 74 u/L (8 - 60) Albumin 49 g/L (35 - 50) Ferritin 404 ug/L (20 - 230) Iron 22 umol/L (10-30) Total iron-binding capacity 69 umol/L (43-80) Discussion Whatwentwell? Whatcouldbeimproved?Q&A MoretoCome! 12 February (Mon), 6.30pm MockOSCE1 In-person, G.13 MST Doorway 4 15 February (Thurs), 6.30pm In persDoorway 4MST MockOSCE2 Thankyou! Slides from the teaching session and a certificate of attendance would be sent out upon completion of the feedback form CREDITS: This presentation template was created by Slidesgo,& images by Freepik.Flaticon, and infographics Please keep this slide for attribution.Practice MCQs Hb 140 g/L Male: (135-180) Female: (115-160) Platelets 170 150-400 WBC 15 (4.0 – 11.0) Question1 A 60-year-old female presents to the ED MCV 90 (80-100) with 2-day history of worsening upper abdominal pain, fever with associated Bilirubin 26 (3-17) nausea and vomiting. On examination, there is a visibly yellow tinge of her sclera. There is tenderness in ALP 340 (30-100) the right upper quadrant. There is no ALT 35 (3-40) guarding or rigidity on light abdominal palpation. Murphy's sign is negative. GGT 40 (8-60) What’s your next course of action?Answer - Results shows leukocytosis (Infection) and signs of cholestasis (Increased ALP and bilirubin) - Diagnosis: Ascending cholangitis (Charcot’s triad: Fever + Jaundice + RUQ pain) - Perform an abdominal ultrasound - IV antibiotics - Elective ERCP after 24-48 hours Creatinine 78 (30 5 days Male 59-104 ago) Women 45-84 eGFR 92 >90 Urea 14.3 2.5-7.8 Sodium 148 135-146 Potassium 5.5 3.5-5.3 Question2 A 40-year-old ,am presented to the Emergency Department with haematemesis. A U&E test has been taken alongside FBCs and LFTs and is shown here. What do you think is happening? What is the next course of action?Answer - Acute kidney injury from high urea and creatinine (although within normal range, creatinine rose more than 50% over 7 days) - High urea due to upper GI Bleed (Protein meal) - Give the patient a fluid challenge and repeat U&Es - If potassium continues to increase, perform an ECG Initial TSH 6.4 0.5-5.5 eGFR 10.4 9.0-18.0 3 months later Question3 TSH 6.1 0.5-5.5 Free T4 11 9.0-18.0 A 34-year-old woman presents with tiredness, weight gain and irregular periods. TPO Ab Positive She is noted to have abnormal thyroid function tests, but all other blood tests are normal. She is not pregnant or planning to conceive. Her vital observations and neck examination are normal. Her pelvic ultrasound is unremarkable. Thyroid tests are repeated 3 months later. What is the next course of action?Answer - Offer 6 month trial of levothyroxine - Diagnosis: Subclinical hypothyroidism