Interpreting blood tests

Note: this is a highly edited section of the notes and merely illustrates what the course offers Diagnosis and management
of long term conditions
Dr Andrew Blann
Consultant Clinical Scientist and
Honorary Senior Lecturer in Medicine
City Hospital, Birmingham
9.15-9.30 Registration 9.30 Introduction, Learning Objectives Key features of diagnosis and management 10.00 The risk factors for atherosclerosis: smoking, obesity Diabetes, hypertension, dyslipidaemia 10.30 (approx.) Break 10.50 Atherosclerosis and heart disease: myocardial infarction, stroke, Heart failure, atrial fibrillation 11.30 Cancer 12.30 (approx.) Lunch 1.30 Inflammatory and auto-immune disease 2.00 Pulmonary disease 2.30 Bone, metabolic and endocrine disease 3.00 (approx.) Break 3.20 Cases 4.30 Review of objectives, discussion, Close Note: this is a highly edited section of the notes and merely illustrates what the course offers Objectives
Having completed these notes in a satisfactory manner, you will…. 1. Appreciate the problems that long term conditions (LTCs) bring to the community 2. Recognise the major groups of illnesses that make up the LTCs 3. Explain the reasoning behind collecting together individual different LTCs into the six different groups, and the relationships between them. 4. Understand the value and limitations of signs and symptoms, imaging, and blood tests 5. Develop a sense of the relationships between the tools available for diagnosis and imaging, and the aetiology and pathophysiology of each particular LTC 6. Recall the diagnosis and management of cardiovascular disease and its risk factors 7. Outline the diagnosis and management of cancer and inflammatory/autoimmune 8. Describe the diagnosis and management of pulmonary, endocrine and metabolic And so…………………………………………………….…………………………. Introduction
 A health problem that can’t be cured but can be controlled by medication or other therapies. Examples of long term conditions include high blood pressure, depression, dementia and arthritis.  Long-term of chronic conditions are illnesses that cannot be cured and that people live with for a long time, such as diabetes, heart disease, dementia and asthma.  Conditions, such as diabetes, asthma and arthritis that cannot currently be cured, but whose progress can be managed and influenced by medication and other therapies. The problem with these definitions is cancer. Although this disease is treatable, complete eradication is often impossible. However, in some cases, such as an anatomically well-defined and non-metastatic tumour, the complete cure is surgery. Therefore, for the purposes of this document, a LTC is any non-acute condition or disease that brings with it increased morbidity and risk of mortality. Note: this is a highly edited section of the notes and merely illustrates what the course offers Diagnosis
The most effective tools in diagnosis and management are signs and symptoms, imaging, and the laboratory. Signs and symptoms The primary problem with signs and symptoms are those of verification, sensitivity and specificity. Patients show remarkable variability in the degree to which they report symptoms of the same disease (for example: changes in frequency of urination and defaecation, backache, tiredness and dizziness, pain in particular areas). Imaging These methods include ultrasound, X-ray, echocardiography, magnetic resonance imaging (MRI) and computer assisted tomography (CAT scanning). The latter four are only found in secondary care, where trained professionals are available to interpret the results. The laboratory This department offers a variety of tools applicable to the community practitioner. Samples of sputum and swabs from a wound or elsewhere can help identify a pathogenic microbe, and thus point to diagnosis (of an infection) and suggest management (perhaps antibiotics). A high white blood cell count over 40 x 106 cells/mL has almost 100% specificity for leukaemia, whilst a normal D-dimer result effectively excludes a diagnosis of deep vein thrombosis or pulmonary embolism. A combination of diagnostic methods Fortunately, many problems of sensitivity and specificity, an in interpretation, can be improved by combining these tools. Epistaxis is a common problem in people with a low platelet count, but nosebleeds may be due to other causes, such as nasal anatomy, in which case the platelet count would be normal. Management
Once diagnosis is confirmed, management can proceed, and there are several methods by which this can be achieved. Non-pharmacological Drugs are often very effective, but are generally expensive and may have undesirable side effects, so that alternatives are preferred and should be sought wherever possible. Pharmacological Should the non-pharmacological approach fail, other methods are likely to be needed. However, no drug is free of a side-effect, as evidenced by the large sections of warning in the British National Formulary. Surgery Should other approaches prove unsuccessful, surgery may be necessary. Indeed, the need surgery has been described as an admission of the failure of the medical approach. Diabetes
Epidemiology As of September 2013, three million Britons suffered from diabetes, with a further estimated 850,000 undiagnosed. However, with the ‘pre-diabetes’ diseases of impaired glucose tolerance (IGT) and impaired glucose tolerance (IGT) this may easily reach 5 million. Note: this is a highly edited section of the notes and merely illustrates what the course offers Diagnosis The key tests are insulin, blood glucose and glycated haemoglobin (HbA1c). Management The first focus is on the amount of glucose in the blood. As this fluctuates during the day, and is dependent on the carbohydrate load of the diet, it best assessed by HbA1c. The first line of management (as in many conditions) is non-pharmacological, with avoidance of sugary foods rich in ‘pure’ sugars such as glucose, sucrose and fructose. Table 2: References ranges for HbA1c
Insulin There are several different families of drugs used to treat the hyperglycaemia of diabetes. The first line in type 1 disease is regular injections with insulin. Drugs In type 2 disease, oral drugs dominate (although some must be injected), and as with insulin, there are many different types. The sulfonylureas act by stimulating the beta cells of the pancreas to secrete more insulin. The second class of drugs are the biguanides, of which the only member is metformin. Pioglitazone, which reduces the resistance of the body to insulin, is the only member of a class of drugs called thiazolidinedione. The most recently developed major class of drugs are the ‘gliptins’. Combination therapy in type 2 diabetes In many cases, these drugs can be used a
monotherapy, However, as several of these classes exert their effects in different ways, they
may be combined for greater efficacy in those who fail to respond to their first line agent.
Metformin (850 mg) is available combined with pioglitazone (15mg) in a single tablet called
Competact. For the most resistance cases, triple therapy of metformin, a sulfonylurea and
then insulin, pioglitazone or a gliptin may be required.
NICE The importance of diabetes as a general health issues can be gauged by the large
number of NICE clinical guidelines (CG), technology appraisals (TA), quality statements and
clinical pathways.
Diabetes and pregnancy Perhaps 4-5% of women develop diabetes during pregnancy (hence
gestational diabetes mellitus) most often in their second or third trimester. Indicators for
screening for gestational diabetes include BMI above 30 kg/m2, Previous baby weighing 4.5
kg or above, Previous gestational diabetes and First-degree relative with diabetes.
Problems in management These can be described in two groups: side effects and
hypoglycaemia. The latter is a particular problem in type 1 diabetics who may ‘overdose’ on
their insulin, and/or use up or fail to maintain their existing glucose levels. Many drugs are
excreted via the kidney. Accordingly, doses should be reduced in the light of a falling eGFR,
and in stage four and five chronic kidney disease, may need to be stopped.

ACE and renin inhibitors
Too much of a molecule called renin can promote high blood pressure. Angiotensin
converting enzyme (ACE) is a key intermediate in the production of renin, so that inhibitors
Note: this is a highly edited section of the notes and merely illustrates what the course offers of this enzyme (hence ACEIs) are effective blood pressure lowering agents. There are several ACEIs, all taking the suffix –pril. Commonly used ACEIs and typical doses are shown in Table 4. Aliskinen is a direct renin inhibitor, used at a dose of 150 mg od, increasing if necessary to 300 mg od. Table 4: Commonly used ACE inhibitors
Recommended daily dose
12.5 mg bd rising to 50 mg bd or tds in highly resistant disease Initially 5 mg od, rising to 20 mg od (maximum 40 mg) Initially 10 mg od, rising to 20 mg od (maximum 80 mg) Initially 4 mg od in the morning, rising to maximum of 8 mg od Initially 1.25 – 2.5 mg od, rising to maximum of 10 mg od

In 2011, 143,181 people in England and Wales died of cancer (5). Of those that are non-sex
specific, the most common were lung, trachea and bronchus (causing 21.1% of deaths),
followed by colo-rectal and bowel (9.8%), and then cancer of white blood cells (7.6%) and
pancreatic cancer (5.2%)(Table X). Prostate cancer was the second most frequent cause of
death in men (12.8% of men), whilst breast cancer was the second most frequent cancer killer
of women (15.2% of women). Cancer of the uterus, cervix and ovary killed almost as many
women (9.2%) as did colo-rectal cancer (9.5%).
Table 1: Deaths due to cancer
Both sexes
All cancers
Lung, trachea and bronchus
Bowel (colon, rectum and anus)
Cervix, uterus and ovary
White blood cells
(Source: Office of National Statistics, 2011) Note: this is a highly edited section of the notes and merely illustrates what the course offers
Case report 2

A 63 year old man with type 2 diabetes, a body mass index of 28.5 kg/m2, mildly reduced
renal function, and a below knee amputee, is seen at his home by the District Nurse. She is
concerned that his remaining foot feels cool and is pale, and takes some blood. Whilst doing
so, the patient recalls a blood test was done “months and months ago”. On examination today
his systolic/diastolic blood pressure is 142/82 mm Hg. His medications are amlodipine 5 mg
once a day, frusemide 40 mg twice a day, ramipril 5 mg once a day, simvastatin 20 mg once a
day and metformin 1000 mg once a day. A week later you review his blood results and
compare them with bloods taken nine months ago.
The remainder of the case discusses these results and potential changes in management


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