Clinical Investigations
Bradford VTS Clinical Resources
- by Dr Ramesh Mehay
- Last modified: 2nd May 2024
- No Comments
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Some basics
The art of medicine is not doing every test under the sun and then working out what the diagnosis is. Anyone can do that!
And besides, if you did do that, you would break the NHS in terms of resources.
The AKT and SCA exams test you to see whether you are doing FOCUSED PURPOSEFUL tests or whether you are just doing anything or everything. The latter is not good doctoring.
- The art of medicine is knowing what tests to do that are necessary.
- In other words, selecting focused investigations where necessary in contrast to doing a battery of tests without much thought.
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Also tell the patient: Other Measures…
- Take some rest
- Drink plenty of sugar-free fluids. Aim to drink at least three litres (five pints) a day, UNLESS YOU HAVE HEART FAILURE – see box on right.
- Try to keep to your normal meal pattern, but if you are unable to, see box on right.
- Avoid too much caffeine as this could make you dehydrated.
- Take painkillers in the recommended doses as necessary.
- Contact your GP to see if treatment with antibiotics is necessary.
- If you are vomiting uncontrollably, contact your GP or call 111
SPECIAL CASES…
Oral fluids in patients with Heart Failure
- Ask your Heart Failure nurse or GP or ring 111 about how much fluid you should drink.
- You may need to stick to around 1.5-2 litres.
- Weigh yourself every day.
- If you suddenly gain more than 2Kg in 3 days, contact the emergency doctor or call 111.
If you cannot eat your normal meals…
- You can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as
- yoghurt,
- milk and other milky drinks,
- fruit juice or
- sugary drinks such as Lucozade, ordinary cola or lemonade.
- You may find it useful to let fizzy drinks go flat to help keep them down
If you are a diabetic on insulin or diabetes medication…
- Keep taking your insulin or diabetes medications even if you are not eating. HOWEVER, stop metformin and blood pressure medication if you are dehydrated.
- Test your blood four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
- Test your urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
- Testing for ketones
- When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
- If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
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Specific Bloods
Vitamin B12 deficiency has various causes and affects individuals differently, requiring tailored diagnosis and treatment.
Nitrous Oxide (Laughing Gas) as a cause of B12 deficiency
Nitrous oxide is also frequently used as a recreational drug by 16 to 24-year-olds. Intensive, frequent use of laughing gas can lead to vitamin B12 deficiency. The gas can make people relaxed, giggly, light-headed or dizzy, but it can also cause headaches and make some users anxious or paranoid. Heavy use can lead to a vitamin B12 deficiency that damages nerves in the spinal cord. Use plasma homocysteine or serum methylmalonic acid as the initial test for patients suspected of having a deficiency caused by recreational use of nitrous oxide.
Other Investigations
- Initial diagnostic tests recommended for individuals with at least one symptom/sign and one or more risk factors.
- Initial diagnostic blood testing can use total B12 or active B12
- active B12 for pregnancy, breastfeeding
- active B12 NOT for those whose suspected vitamin B12 deficiency may be caused by recreational nitrous oxide use.
- Follow-up tests, such as measuring methylmalonic acid (MMA) concentrations, may be considered in certain cases.
Life Long Treatment with B12
Lifelong intramuscular vitamin B12 replacement is recommended for specific patient groups.
- Autoimmune gastritis
- Any chronic inflammatory disease that destroys parietal (acid-secreting) cells in the stomach
- Pernicious anaemia
Urgent conditions requiring immediate B12 Rx
Treatment should not be delayed for
- severe megaloblastic anaemia
- sub-acute combined degeneration of the spinal cord.
x
x
x
Also tell the patient: Other Measures…
- Take some rest
- Drink plenty of sugar-free fluids. Aim to drink at least three litres (five pints) a day, UNLESS YOU HAVE HEART FAILURE – see box on right.
- Try to keep to your normal meal pattern, but if you are unable to, see box on right.
- Avoid too much caffeine as this could make you dehydrated.
- Take painkillers in the recommended doses as necessary.
- Contact your GP to see if treatment with antibiotics is necessary.
- If you are vomiting uncontrollably, contact your GP or call 111
SPECIAL CASES…
Oral fluids in patients with Heart Failure
- Ask your Heart Failure nurse or GP or ring 111 about how much fluid you should drink.
- You may need to stick to around 1.5-2 litres.
- Weigh yourself every day.
- If you suddenly gain more than 2Kg in 3 days, contact the emergency doctor or call 111.
If you cannot eat your normal meals…
- You can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as
- yoghurt,
- milk and other milky drinks,
- fruit juice or
- sugary drinks such as Lucozade, ordinary cola or lemonade.
- You may find it useful to let fizzy drinks go flat to help keep them down
If you are a diabetic on insulin or diabetes medication…
- Keep taking your insulin or diabetes medications even if you are not eating. HOWEVER, stop metformin and blood pressure medication if you are dehydrated.
- Test your blood four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
- Test your urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
- Testing for ketones
- When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
- If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
x
x
c
x
- x
Clincal Investigations
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