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Table of Contents
In clinical practice, investigations are sometimes grouped together into “sets”, “panels” or “screens” that focus on specific clinical presentations (e.g. confusion/anaemia). The aim of these screens is to rule common causes of a given clinical presentation in or out. It is worth having some knowledge of what tests are included in each of these investigation panels, so we’ve summarised some of the most common screens below.
Confusion screen
Clinical assessment
Vital signs: sepsis/hypotension
Clinical examination:
- Level of consciousness (e.g. GCS/AVPU)
- Evidence of head trauma
- Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
- Asterixis (e.g. uraemia/encephalopathy)
Lab tests
Full blood count: raised WCC may indicate infection
CRP: often raised in the context of infection
U&Es: uraemia/hyponatraemia
Bone profile: hypercalcaemia/hypocalcaemia
B12 & Folate: deficiency can cause confusion
Thyroid function tests: confusion is more common in hypothyroid states
Glucose: hypoglycaemia is a common cause of confusion
LFTs: confusion can occur secondary to liver failure (hepatic encephalopathy)
Coagulation/INR: particularly important for those patients on anticoagulation who may have had an intracranial bleed
Other investigations
CT head: if there is concern about intracranial pathology (bleeding, ischaemic stroke, abscess)
Anaemia screen
Clinical assessment
Vital signs: hypotension and tachycardia may indicate active bleeding
Clinical examination:
- General pallor/conjunctival pallor
- Clinical signs of malignancy (e.g. abdominal mass/cachexia)
- Rectal examination: malaena/malignancy
Lab tests
Full blood count: will provide haemoglobin level/MCV/haematocrit/platelet count
Thyroid function tests: hypothyroidism can cause macrocytic anaemia
U&Es: chronic kidney disease can cause anaemia (due to reduced erythropoietin production)
Haematinics:
- B12 and folate: deficiency causes a macrocytic anaemia
- Ferritin
- Serum iron
- Total iron-binding capacity (TIBC)
Other investigations
Colonoscopy/gastroscopy: may be appropriate if there are concerns regarding gastrointestinal blood loss
CT chest, abdomen and pelvis: if there are concerns about malignancy
Sepsis screen
Clinical assessment
Vital signs: blood pressure, pulse, respiratory rate, oxygen saturation and temperature
Clinical examination:
- Assessing for potential sources of sepsis (e.g. chest/urine/skin/intra-abdominal)
Lab tests
Full blood count: raised WCC may suggest infection
CRP: often raised in the context of infection
U&Es: acute kidney injury is common in sepsis
Lactate: raised in sepsis secondary to reduced end-organ perfusion
Blood cultures: to enable the causative organism to be identified
Other investigations
Urine sample: dipstick and culture
Sputum sample: culture
Stool sample: culture
Wound swab: culture
Hyponatraemia screen
Clinical assessment
Clinical examination:
- Assessing current hydration status (hypervolaemia/euvolaemia/hypovolaemia) is important to help narrow the differential diagnosis of hyponatraemia
Lab tests
U&Es: to assess the degree of hyponatraemia, other electrolytes and renal function
Serum osmolality + urine osmolality + urinary sodium/potassium: useful for confirming a diagnosis of SIADH
Thyroid function tests: hypothyroidism can cause hyponatraemia
Serum cortisol: Addison’s disease is a potential cause of hyponatraemia
Hypocalcaemia screen
Clinical assessment
Clinical examination:
- Assess current hydration status
- Assess urine output
Lab tests
U&Es: to assess other electrolytes and renal function
Bone profile: to assess calcium and phosphate levels
Ionised calcium
Parathyroid hormone (PTH): hypoparathyroidism is a potential cause of hypocalcaemia
Vitamin D: deficiency is a cause of hypocalcaemia
LFTs: to assess albumin level
Refeeding syndrome screen
Clinical assessment
Clinical examination:
- Nutritional status: intake/output
- Fluid status
Lab tests
U&Es: hyponatraemia/hypokalaemia
Bone profile: hypophosphataemia/hypocalcaemia
Magnesium: hypomagnesaemia
Other
ECG: deranged electrolytes such as potassium and phosphate can cause fatal arrhythmias
Myeloma screen
Clinical assessment
Clinical examination:
- Clinical signs of anaemia (e.g. pallor)
- Areas of bony pain
Lab tests
FBC: anaemia/neutropenia/thrombocytopaenia
U&Es: raised creatinine/hypercalcaemia
ESR: raised
Blood film: rouleaux formation (red cells stacked on each other) is typical in myeloma
Protein electrophoresis of blood and urine: raised levels of Bence Jones protein are typical (appearing as a paraprotein band)
Immunoglobulins: measurement of IgG/IgM/IgA can be useful to identify immune paresis.
Imaging
Skeletal survey:
- A series of X-rays of the skull, axial skeleton and proximal long bones to identify the typical lytic lesions associated with multiple myeloma.
- MRI is more sensitive than X-ray at detecting lytic lesions, particularly those in the vertebrae.
Bone marrow biopsy
To assess the percentage of bone marrow occupied by plasma cells (this helps with diagnostic stratification).
Liver screen
Clinical assessment
Clinical examination:
- Examine the abdomen and assess for stigmata of liver disease
Liver function
LFTs
Coagulation screen
Viruses
Hepatitis serology (A/B/C)
Epstein-Barr Virus (EBV)
Cytomegalovirus (CMV)
Autoimmune antibodies
Anti-mitochondrial antibody (AMA)
Anti-smooth muscle antibody (ASMA)
Anti-liver/kidney microsomal antibodies (Anti-LKM)
Anti-nuclear antibody (ANA)
p-ANCA
Other
Immunoglobulins: IgM/IgG
Alpha-1 Antitrypsin: Alpha-1 antitrypsin deficiency
Serum Copper: Wilson’s disease
Ceruloplasmin: Wilson’s disease
Ferritin: haemochromatosis
Liver biopsy