" Decision Oriented Lab Laboratory Testing A Physicians guide...

"

By "Dr Deepak Daswani , MD.......consultant......."

 Contents
I INTRODUCTION 4
How are lab tests currently requested ? 4
How to effectively order lab tests - "The Diagnostic Reasoning Approach" 6
"Decision Oriented Test Request Forms" 9

II DOT PANELS 14
Cardiovascular System 14
Respirotary System 14
GI Tract and Pancreas 14
Hepatobillary Tract 14
Urogenital Tract 15
Endocrine Systems 15
Haematology 16
Acid Base Disorders 17
Autoimmune Disorders 17
Infectious Diseases 17
Mineral / Bone Disorders 22
Skeletal Muscle Disorders 22
Joint Diseases 23
Cancer 23
Prenatal and Neonatal Diagnosis 24
General 25
Introducing the First Ever,"Alchoholism Index" 26

III ENDORSEMENTS 27
Dear Friend

Let me introduce myself. I am a Consultant Pathologist specializing in "Clinical Laboratory

Medicine" I own & manage' Jyoti Pathology Laboratory, situated at Colaba Mumbai. My laboratory
offers. all routine tests in: Clinical pathology, haematology, biochemistry, serology; microbiology
as well as surgical pathology & cytology services. I have also recently introduced
Immunafluorescence microscopy for blood parasite detection.

As you may well be aware, technology nowadays has increased the number, variety & complexity
of lab tests to such an extent that they "outstrip the ability of the physician," to keep informed
about their diagnostic utility, & more importantly their interpretation in clinical situations.
"Everytime a physician faces a medical diagnosis, he/she has to select from about 1000 tests at
any given time". Obviously then selecting the appropriate tests further applying their findings to
achieve a diagnosis can be an extremely mind boggling task !!!

At present physicians have no option but to choose from "test request lists/brochures/booklets"
which basically resemble "a la carte like menus" [whether from large hospitals; specialized
reference labs, private labs, or diagnostic centres], These test request formats in no way, help the
physician in the diagnostic process.

"The Decision Oriented Approach to Laboratory Testing ©" - DOTS; is based on

categorization, of almost all common as well as complicated medical disorders, into "problem
solving strategies", termed "DOT -PANELS". These panels differ from the routinely used
"Profiles", in that they are "structured to contain the right mix of tests"[either screening,
diagnostic or monitoring]. These panels therefore, effectively cover all possible approaches,
towards lab management of most medical disorders.

Well Doctors, if you knew of only 20-30 profiles as of

today, I offer you a choice of more than 400 profiles !!!!

A brief mention regarding the "utilty of interpretive reporting". Interpretive reports by the
pathologist, give meaning & knowledge to raw lab data, thereby increasing their informative
content. Besides saving precious time & effort of the physician, interpretive reports guide the
physician, to focus on important facts. while at the same time overlook irrelevant data. The
diagnostic possibilities, suggested by the pathologist (from test values) are similar to provisional
diagnosis, conceptualised by the physician [from clinical history, signs, symptoms] & ideally
should not be ignored. However physicians have the same prerogrative of accepting or rejecting
the suggestion as for any other consultant.
Finally friends, in the next few pages, I have taken the liberty of sharing a few thoughts with you,
regarding the current scenario in lab testing. I hope the new concept of "Decision Oriented
Laboratory Testing" will in some way, change the attitudes and approach, towards clinical
diagnosis & management by lab methods. Looking forward for your support.

Regards
Dr. Deepak H. Daswani
 INTRODUCTION

How are lab tests currently requested ?

Whether it is major hospitals, large or small volume path labs, speciality reference labs or
diagnostic centres; the appearance of test request forms/slips are all alike. The tests are arranged
like "little ticket items" which have to be ticked off. These menus mostly contain lists of individual
tests, along with some "multitest profiles" [ex SMA 12, Pacer 22; 26: profiles [liver; kidney;
cardiac: body etc.].

“It is the content of the panel & not the concept, that has been problematic" These
"menus" are based on the fact "at tests have been traditionally segregated by the technology by
which they were performed. Hence he distinction into arbitrary categories like: Haematology;
clinical pathology; biochemistry; immunology; microbiology, histopathology; blood banking etc.
"typical of hospital menus"]. Non specific categories like Routine; Hormones; Elise: Serology;
Bacteriology are "typical of private labs".

Although for the purposes of a price list or services offered these categories would
suffice, but by no stretch of imagination, would these lists give the physician, any clue
as to selection of appropriate tests, to make a diagnosis.

Physicians role, in Total Quality Management [TQM] in Medical

Diagnosis — "Chicken or the Egg situation"

It is generally assumed that, the laboratory is solely responsible, for total quality management in
diagnosis. To a large extent this is true, since technically speaking, the correct result depends on
the correct test analysis. "The Lab information Loop" (is an excellent) representation of variables
associated with lab testing. As you can see a "wrong report" could be generated due to an error at
any stage in the loop:
Faulty sampling [C]; specimen processing [D]; bad equipment or reagents[E]; poor quality control
[F]; Any of these can render report useless, despite the best management systems. "However the
bottom line is that, if the appropriate tests are not requested by physician, effective test report
[G] by pathologist is not possible, hence the whole process of lab testing is futile.
"The Lab Information Loop" Fig [1]

Of the Internationally accepted criteria for TQM; two are most relevant :-

1. "The tests requested by the physician must be appropriate to the medical problem"
[A]Effective medical diagnosis would require first of all, appropriate tests be chosen by the
physician.

2. Professional Judgement (interpretive report) by a pathologist,

having an applicable & practical medical background [H]

Interpretive reports, close the gap between mere reporting of lab test results, viz a viz their
integration into the diagnostic & management process.
How
to effectively order lab tests "The
Diagnostic Reasoning Approach"

Effective lab test utilization, can only be understood in relation to their clinical context. This
approach provides a useful frame work for the initial confusion as to which type of tests to order.
Ordering of lab tests are usually done for primary medical reasons like:
Screening [wellness case finding]
Diagnosis
Monitoring

1."SCREENING PROFILES - THE FLIPSIDE"

When the question is health v/s illness multitest screening profiles ["SMA 12; Pacer 22; Pacer 26"]
in general have not proven to be beneficial. The single most important reason is "The unexplained
abnormal test result". It is known that the probability of an abnormal result. (result above the
reference Lange); would represent a "statistical outlier" If it did not fit in with any clinical
findings.

Unexplained Abnormal Test Results FIG. [2]

No. of tests Probability (%) of findings
in screening panel results outside reference range
8 25
12 43
20 55

It should be noted here, that reference values represent statistical data for 95% of the population.
"These statistical outliers" therefore may or may not represent disease. "The probability of these
unexplained abnormal results, increase with the number of tests in the screening panel" Fig [2]

What actually happens is that, with any unexplained abnormal test result, "the physician faces the
dilemma, whether to ignore the finding or follow it". In most cases, the physician follows up with
extensive investigations. This leads to the "Ulysses Syndrome" [like Ulysses the greek
mythological character, the patient has to pass through a long journey of investigations before he
is declared fit].This obviously, is traumatic to the patient in more ways than one.

A sure shot way to tackle the problem of the "unexplained abnormal result", would be to "discount
physiological variables" [age; sex; stress, exercise; pregnancy; diet etc.] as well "as preanalytical
variables" [specimen collection; effects of drugs etc]. If all of these do not explain the abnormal
result, then "repeat or serial testing at intervals", would finally decide whether test was actually
abnormal.
The most common single test abnormalities in screening panels [SMA 12; Pacer etc] are
seen with: Calcium; Alkaline Phosphatase; Albumin; Glucose; Sodium;

2.CASE FINDING -A CASE FOR PROFILES"

Profiles [ex. Liver; Kidney; Thyroid; Lipid etc] are of use only in case findings i.e. testing
individuals symptomatic for a particular organ system disease, by tests used for other organ
system. Examples are:-

Thyroid profile: For patients with Atrial fibrillation, or recently diagnosed hyperlipadaemias;
infertility in women, normocytic anaemias; elderly people admitted to hospitals.

Liver profile: For patients with coagulopathies [increased prothromobin time; PTT etc];
hyperlipidaemias; normocytic anaemia & electrolyte imbalances (Hypo/hypernatremias)

Kidney profile: For chronic diabetics; long standing hypertensives, Acid base abnormalities
(metabolic acidosis); electrolyte imbalances [hypo/hypernatremia]; Renal osteodystrophy
Normocytic anaemias.

Lipid profile: In Diabetics; chronic liver diseases (ex. obstructive jaundice), kidney disease (ex.
nephrotic syndrome; chronic uraemia); chronic alcoholism, obesity etc.
In these situations, results of profiles will provide a clue as to whether there is presence or
absence of disease.

3.DIAGNOSTIC TESTS - "THE GUIDED MISSILE APPROACH"

Like "guided missiles" diagnostic tests should home onto the target (diagnosis). This can only
be achieved by a structured approach to testing. Ideally the "right mix" of diagnostic tests should
either: Confirm a diagnosis; Exclude a diagnosis; Clarify a diagnosis; Provide clues to an unclear
diagnosis.

Some important situations where diagnostic tests, coupled with interpretive reports, would be of
use are:

Anaemia
Hepatitis
Thyroid disorders
Metabolic problems [Hypercalcaemia; Hypo or hypernatremias; Acid base disorders etc.]
Autoimmune disorders
Complex haematological disorders [ex. Leukaemias; Lymphomas; Coagulopathies1]

4. MONITORING TESTS - "PIGGY BACK CONTROL"

If diagnostic tests sort out the diagnosis; monitoring tests on the other hand "piggy back" on the
diagnostic tests. If the disease has recently been diagnosed or is already known, then
monitoring tests are useful for : Monitoring course of disease; Monitoring therapy;
Staging severity of disease; Providing prognostic parameters:

Some important situations where monitoring tests would be of use are:

Leukaemias/Lymphomas/Myelomas
Pancreatitis (Acute & chronic)
Hyperlipidaemias (primary/secondary)
Tumour markers [ex. CEA (colon cancers); CA 125 (ovarian cancers); AFP (liver & germ cell
tumors), PSA (prostate cancers) etc]
Chronic renal failure
Viral hepatitis

"Decision Oriented Test Request Forms" - DOT PANELS

It is entirely possible, to categorize common & complicated medical problems (within their
respective organ systems). These problems can then be viewed in the format of so called "DOT
PANELS". The type of tests utilized in these panels, would determine whether any given panel is
ideal for either :- "screening, diagnostic or monitoring purposes".

Advantages of DOT PANELS

Appropriate Tests: Not only do these panels ensure that the correct tests are requested, they
also ensure that, unnecessary or outdated tests are eliminated, while at the same time new
accurate tests are introduced.

Interpretive Reports: Test results can be communicated "in the same format" as that of request
form, hence improving the diagnostic utility of the test results.

Strategy Implementation: DOT PANEL - request forms, allow implementation of: "optimal
screening, diagnostic & monitoring strategies"
Presented below are examples of how DOT - PANELS score over the conventional profiles [note
tests have been ommited]. Only the diagnostic utility of these panels are highlighted.

LIVER PROFILE - CONVENTIONAL [Fig. 3]

Constituent Tests Type of Profile Diagnostic Value [Specific Diagnoses Achievable]

SGPT S
SGOT C
ALK R
GGT E Non Specific
Bilinubin E
Total Protein N
Albumin

LIVER - DOT PANELS [Fig. 4]

DOT Panels Type of Panel Diagnostic value [Specific Diagnoses achievable]

Acute Hepatitis Diagnostic Viral; Alcoholic & Drug Induced Hepatitis
Chronic Hepatitis Diagnostic Viral & Autoimmune & Hepatitis Biliary Cirrhosis;
Obstructive Jaundice
Alcoholic Hepatitis Screen Alcoholism; Fatty Liver; Alcoholic hepatitis

Cirrhosis Diagnostic Nodular type; Terminal (with Acites)

Cholestasis Screen Intra hepatic & Extra hepatic Cholestasis

SOL/Metastatic Profile Screen Metastasis; Hepatoma; Liver abscess

ANAEMIA SCREEN - CONVENTIONAL [Fig. 5]

Constituent Tests Panel Type Diagnostic value [Specific Diagnoses Achievable

CBC S Microcytic Anaemia
C

RDW R Macrocytic Anaemia

E

Retic counts E NormocyticAnaemia

N

ANAEMIAS - DOT PANELS [Fig. 6]

DOT - Panels Type Diagnostic value [Specific Diagnoses achievable

Microcytic Hypochromic Diagnostic Iron Deficiency; Anaemia of

Chronic Disease; Thalassaemia.

Macrocytic Diagnostic MegaloblasticAnaemia [vit B12] Folic acid]; Non

megaloblastic; anaemia [endocrine & liver
disease]

Normocytlc Screening HaemolyticAnaemias; Non haemolytic anaemias

[Chronic inflammation; Renal endocrine & liver
diseases]

Normocytlc Diagnostic Drug induced haemolytic anaemia; Cold

agglutinin; Spherocytosis; Elliptocytosis; Microangiopathic
Anaemia; Haemoglobinopathies; Aplastic Anaemia;
Malignancies.

KIDNEY PROFILE- CONVENTIONAL [Fig. 7]

Constituent Tests Type of Profile Diagnostic Value [Specific Diagnoses Achievable]

BUN
Creatinine S
Bicarbonate C
Electrolytes R Non Specific
Calcium E
Phosphorus E
Total Protein N
Albumin
KIDNEY - DOT PANELS [Fig. 8]

DOT - Panels Type Diagnostic value [Specific Diagnoses achievable]

Proteinuria Diagnostic Conditions causing glomerular; tubular overflow &
low grade proteinuria

Haematuria Diagnostic Conditions causing glomerular & non glomerular

Haernaturia.

Acute Renal failure Diagnostic Differentiating types Pre renal; Renal & Post renal

Glomerulo nephritis Diagnostic Acute GN; MPGN; RPGN; [GN panel]

Membrainous nephropathy; Minimal change
disease.

Glomerular Disease Diagnostic Diabetic nephropathy; Nephrotic syndrome

panel

Tubular Disease Diagnostic Acute interstital nephritis; Acute Tubular necrosis;

Chronic Interstital nephritis

Urinary tract infections Screen Pyelonephritis; Urethritis; Sterile pyuria; Acute

urethral syndrome; Cystitis Prostatltis

Nephrolithiosis Diagnostic Primary Hyper parathyroidism Hypercalciuria

"DOT PANELS - UNPLUGGED"

[An Idea whose time has come]

Presented below are "more than 400 DOT PANELS". These Span 10 organ systems & important
clinical categories like: Acid base & Electrolyte disorders; Autoimmune disorders; Infectious
diseases; Tumour markers; Prenatal (neonatal diagnosis) & inherited disorders of metabolism.
These panels coveralmost all common (& not so common) diseases in current existence.
I have deliberately omitted the tests within these panels (due to space constraints). "The intention
here, is to convey the concept of these panels in focussed diagnosis".

WHAT DOT PANELS ARE

The right mix of tests: to guide the physician towards a fast & accurate diagnosis
Strategy Implementation: In screening, diagnosis or monitoring situations.
Multipurpose use: Can double up as request forms, as well as Interpretative reports.

WHAT DOT PANELS ARE NOT

Substitute for clinicians judgement.
"Rigid Frame work" : Tests can be added, deleted & modified as per "real time clinical situation".
Total Solutions: All diagnoses should be achieved as an integration of, Clinical features, Lab tests;
Radiologic & allied methods.
NOTE: In the next section DOT - PANELS, wherever panels are categorised as I, II, or III; unless
otherwise specified, it would indicate the nature of the panel, for example:
I Screening
II Diagnostic
III Monitoring

DOTS PANELS

CARDIOVASCULAR SYSTEM
1. Lipid Panel – Basic
2. Coronary risk factor panel
3. Atherothrombotic Profile

4. AMI - Myocardial damage Markers

5 A M I - M a r k e r s o f complications

6 Congestive Cardiac Failure [CCFI-Panel 1

7. CCF - Panel II

8 Hypertension Panel - I

9 Hypertension Panel - II

RESPIRATORY SYSTEM
1. Pleural fluid analysis Panel -
2. Pleural fluid analysis Panel - I
3. Acute Pharyngitis Panel
4 Acute Resp i ratory Infection Panel - 1

5. Acute Respiratory Infection Panel - II

6 Chronic Respiratory Infection Panel -1

7 Chronic Respiratory Infection Panel -11 [Immuno compromised]

8 Chronic Obstructive Pulmonary Diseases

9 Lung Cancer
GI TRACT AND PANCREAS
1 GI Panel - I
2. Gastric Evaluation Panel - I
3 Intestinal Malabsorption Panel - I
4. Intestinal Malabsorption Panel - II
5. Acute Diarrhaea - Panel 1
6 Acute Diarrhaea - Panel II
7 Chronic Diarrhaea

8.Pancreatic Panel – Basic

9.Acute Pancreatitis

10.Chronic Pancreatitis
11.Pancreatic Carcinoma

12.Acute Abdominal Pain

HEPATOBILIARY TRACT
1. Liver panel - Basic
2. Acute Hepatitis
3. HBV- Acute Phase Markers
4. HBV - Chronic Phase Markers
5. HBV- Carrier Phase Markers
6. HBV- Prenatal screen 7. HDV - Panel
7. HCV - Panel 1
8. HCV Panel 11
9. Alcoholism Index
10. Fatty liver & Alcoholic Hepatitis
11. Acute Fulminant Hepatic Failure
12. Chronic Hepatitis
13. Auto Immune Hepatitis 15, Primary Billary Cirrhosis Panel -1
14. Primary Billary Cirrhosis Panel - II
15. Primary Sclerosing Cholangitis
16. Hemochromatosis
17. Cirrhosis
18. Cholestasis/Billiary obstn
19. Liver Metastatsis
20. Neonatal Hyperbillirubinemia
21. Spontaneous bacterial Peritonitis
UROGENITAL TRACT
1. Renal Profile - Basic

2. Comprehensive Renal Profile

3. Protenuria - follow up

4. Haematuria - follow up

5. Acute Renal Failure

6. Diabetic Nephropathy

7. Nephrotic Syndrome

8. Glomerulo Nephritis Panel-I

9. Glomerulo Nephritis Panel-11

10. Acute Interstitial Nephritis

11. Acute tubular Necrosis

12. Urinary Tract Infection

13. Chronic Renal Failure
14. Nephrolithiasis [Renal Calculi]
15. Renal Tubular Acidosis

16. Urethritis/Cervicitis

17. Prostate Cancer Panel - 1

18. Prostate Cancer Panel - II

19. Male Infertility Panel – 1

20. Male Infertility Panel - II[Gynaecomastia]

21. Male Infertility Panel - III [Impotence]

22. Female Infertility Panel – I [Ovulation defects]

23. Female Infertility Panel - II [POCKS]

24. Female Infertility Panel - III [Hirsutism]

ENDOCRINE SYSTEM
1Diabetes Mellitus Panel - I [Diagnosis]

2 Diabetes Mellitus Panel - 11 [Complications]

3. Diabetes Mellitus Panel - III [monitoring control]

4 Diabetes Mellitus Panel - IV [Monitoring Complications]

5 Hypoglycaemia

6. Diabetes Mellitus -Auto Antibodies

7 Thyroid Panel - Basic

8 Hyperthyroidism Panel -1
9 Hyperthyroidism Panel - II
10. Hypothyroidism Panel - I
11 Hypothyroidism Panels -II
12. Neonatal hypothyroidism

13 Euthyroid sick syndrome

14 Cushing's Syndrome Panel – 1
15 Cushing's Syndrome Panel – II
16 Addison's Disease Panel - I
17 Addison's Disease Panel – II
18 Addison's Disease Panel - |||
19 Hyper aldosteronism
20 Hypo aldosteronism
21 Hypopituitarism Panel – 1
22 Hypo pituitarism Panel – II
23 Phaeochromocytoma
24 Neuroendocrine Tumours
HAEMATOLOGY

1. Anaemia Panel - I [Screen]

2. Microcytic Anaemia Panel -I [Iron deficin]

3. Microcytic Anaemia Panel -II [Thalassemia]

4. Macrocytic Anaemia Panel - I

5. Macrocytic Anaemia Panel - II
6. Haemolytic Anaemia Panel - I
7. Haemolytic Anaemia Panel - II
8. Normocytic Anaemia

9. Neutrophilia/Leucocytosis

10. Acute Neutropaenia/ Leucopaenia

11. Chronic Neutropaenia/ Leucopaenia
12. AML Panel – I
13. AML Panel – II

14. AML Panel - III

15. CML Panel - 1

16. CML Panel - II

17. Polycythaemia Vera

18. Myelofibrosis with Myeloid Metaplasia

19. Essential Thrombocythaemia

20. Lymphocytosis

21. Infectious Mononucleuosis

22. Lymphocytopenia Panel -I

23. Lymphocytopenia Panel - II

24. Primary lmmunodeficiences Panel -I

25. Primary lmmunodeficiences Panel -11

26. Lymphoid Cancer Panel - I

27. Lymphoid Cancer Panel - II

28. Lymphoid Cancer Panel -III

29. ALL Panel -I

30. ALL Panel - II

31. CLL Panel -I

32. CLL Panel - II

33. Multiple Myelorna Panel - I

34. Multiple Myeloma Panel - II

 35. Multiple Myelorna Panel - III

36. Lymphoma Panel - I

37. Lymphoma Panel -11

38. Coagulation Screen

39. Platelet Disorders (functional)

40. Von Willebrand Disease

41. Thrombocytopaenia Panel-I

42. Thrombocytopaenia Panel - II

43. TTP - HUS Profile

44. Thrombocytosis Panel - I

45. Thrombocytosis Panel - II

46. Coagulation disorders Panel-I [Screen]

47. Coagulation disorders Panel - II [Hereditary]

48. Coagulation disorders Panel -III [Acquired]

49. Coagulation disorders Panel - IV [DICI]

50. Coagulation disorders Panel V [Anticoagulant drug effects]

51. Hereditary Thrombotic disorders

52. Acquired Thrombotic Disorders Panel - I

53. Acquired Thrombotic Disorders Panel – II

ACID BASE DISORDERS

1. Acid Base Balance Panel -Basic

2. Electrolyte/ Panel - Basic

3. Hyponatremia

4. Hypernatremia

5. Hypokalernia

6. Hyperkalemia Panel - I

7. Hyperkalemia Panel - II

AUTOIMMUNE DISORDERS
 1. Autoimmune Panel - 1

2. Autoimmune Panel - 11

3. SLE Profile - 1

4. SLE Profile - II
5. Sjogren Syndrome
6. Scleroderma

7. Polymyositis/ Dermatomyositis
8. MCTD
9. Rheumatoid Arthritis

10. Vasculitis Panel - I

11. Vasculitis Panel – II

INFECTIOUS DISEASES

Basic Pathogens Detection Panels

1. Bacteria Detection

2. Viral Detection -

3. Chlamydial Detection -

4. Mycoplasma Detection -

5. Fungal Detection -

6. Parasite Detection -

7. Mycobacterium Tuberculosis - Detection

8. HIV & AIDS - Detection

9. Fever Profile

Systemic Infections -Associated Pathogens

I - SKIN & SOFT TISSUE
A - Abscesses [Impetigo; Folliculitis; Furunculosis]

B - Cellulitis
C - Wound Infectious [Including surgery/post damaged tissue ulcers/ traumatic devitalized
tissue/burn, wound etc]

D-Ulcers [Damaged/ devitalized tissue; necrotic tissue/burns/verrucous ulcers/

mucocutaeneous ulcers]
E -Vesicles/Blisters [Vesicular rash mucocutaenous skin]
F - Erythema Nodosum [nodular lesions; Erythematous lesions/Erythema multiforme & nodosum]
G – Granulomatous Lesions [with/without discharging sinuses]
H - Skin, Hair & nail infections

II - RESPIRATORY SYSTEM

A - Pneumonia [Broncho/ Lobar/Tracheo- bronchitis/ pleuritis/necrotising/ pneumonits]

B - Bronchitis [oefflers syndrome/pneumonitis
C - Chronic Lung Disease [pleural effusion Lung abscess; bronchial colonization bronchiectais
granulomas (TB)]

III - ENT
A - Sinusitis [acute/chronic]
B - Pharyngitis & Tonsilitis [sore throat/Epiglotitis]
C - Otitis Media [acute/ chronic; Mastoiditis/ External ear infection]

IV - GIT
A - Oesophagitis
B - Gastritis/Duodentitis [GI ulcers]
C - Enterocolitis [gastroenteritis Infectious colitis; Diahorreas]

D - Peritonitis [Appendicitis; Cholecystitis]

E - Liver [Hepatits; SOL (liver & gall blader); hepato splenomegaly; Liver abscess; sclerosing;
cholangitis jaundice]
F – Proctitis
G- Acute Inflammatory Conditions [Pancreatitis; Appendicitis; Acute Intest. Obst; Cholecystitis;
Bowel perforl]
H - Organ Abscesses [liver spleen pancreas]

V - MUSCULO SKELETAL SYSTEM

A – Osteomyelitis
 B- Arthritis [Tenn synovitis/ arthralgias]

C - Myositis [Skeletal muscle infiltration/ tendintis/ fascitis/teno synovitis]

VI – OPTHALMIC

A - Orbital Infection
B - Conjunctivitis

Vll - C N S
A - Meningitis
B - Encephalitis
C - Brain Abscess
D - Encephalopathy [Brain Infiltration/Vascular occlusion etc]
E - Neuropathy [mono or polyneuritis/periph eral neuropathy/myelopathy

VIII - CARD VASCULAR

A Endocarditis
B Pericarditis
C Myocarditis

IX - UROGENITAL TRACT
A - Acute Glomerulo - Nephritis [Nephrotic syndrome]

B- Urethritis [male & female; Vulvovaginitis/ Cervicitis]

C - Prostatits [seminal vesicles]
D - UTIs [pyelonephritis; cystitis; post op. catheterization]
E - Female Genital Tract Infections [Salphingitis; N e p h r i t i s ; P e l v i c peritonitis; Endometritis;
Pelvic abscess PID; post part endometritis; Sepsis (post partum; post abortion; perpueral;
post Hysterectomy)]
F - Male Genital Tract Infections [epididimitis, Orchids; Prostatitis Vesiculitis]
G - Ulcers [male & female genital tract]

X - LYMPH NODE
A - Lymphadenitis/ Lymphadenopathy [acute/chronic/ulcerative/ lymphangitis]

XI - BLOOD
A - Bacteremia
B Vire mia
 C Fungemia
D - Parasitaemia
E - Others [TB; Bartonella; Rickettsiae]
F - Haemopoetic System
• Altered WBC counts
• Anaemia
• Haemolytic Anaemia
• Bone Marrow lnfiltn
• Hematologic Malignancies

XII – OPPORTUNISTIC INFECTIONS

A - R e c o g n i z e d (Established) opportunistic pathogens

B - Newly recognized types
C - Pathogens in lmmuno-suppression Humoral [Lymphatic leukemia; Lympho s a r c o m a ;
M u l t i p l e myeloma; Congenitial hypogammaglobulinemias; Nephrotic syndrome; cytotoxic or
antimetabolite drugs]
Cellular [Terminal cancers; Hodgkin's disease; Sarcoidosis; Uremia; Treatment with cytotoxic or
anti-metabolite drugs or corticosteroids]
Leukocyte/ bactericidal [Myelogenous leukemia; Chronic granuiomatous Disease; Acidosis;
Burns; Treatment with corticosteroids; Granulo#cytopenia due to drugs].
D - Pathogens in neoplasms
Acute nonlympho#cytic leukemia [Sepsis with no apparent focus; pneumonia; skin; mouth & GU
tract, hepatitis]
Acute lymphocytic leukemia [Disseminated disease; pneumonia; pharyngitis; skin]
Lymphoma [Disseminated disease; sepsis; GU tract; pneumonia; skin]
Multiple myeloma [Sepsis; Pneumonia, Skin]

E - Opportunistic Pulmonary Infections

Following organ trans-plantation [continuing immuno#suppressive therapy]
Following bone marrow transplanta#tion (initial immuno#suppressive therapy Prolonged
neutropenia, progressive decrease in humoral and cell-mediated immunity).

Specific Pathogen related infections

I - BACTERIAL INFECTIONS
A - Streptococcal Infections - Acute Rheumatic Fever [Street Throat; Post streptococcal
glomerulo-nephritis Endocarditis]
B - Pneumococcal Infections [Endocarditis; Arthritis; Meningitis; Empyemia, Peritonitis]
C - Meningococcal Infections
D - Enteric Fever
E - Neonatal Meningitis [campylobacter fetus; listeriosis]
F - Toxic Shock Syndrome
Streptococcal [Tissue invasion; Bacteremia; Pneumonia; Peritonitis osteomyelitis; Myome#tritis;
Cellulite; Fascists]
Staphylococcal [use of tampoons]
G - Gram Negative Septicaemia [Secondary to infection of GU tract; Uterus; GI tract; Lung;]
H Sepsis Neonatorum [first 30 days of life; blood & meninges involvement]
I Anaerobic Infections [Bowel perforation; acute appendicitis; biliary tract; pelvic abscess; post
partum; post abortion; hysterectmy; Lung abscess, UTIs; soft tissue; Endocarditis]
J Infectious Vasculitis [bacillary Angiomatosis]
K – Endocarditis

II - VIRAL INFECTIONS
A - Torch Panel
Toxoplasma Gondii
Rubella#
CM
HSV
HIV
Parvo virus B19
Enterovirus
B - Viral Infections in lmmuno Compromised [CMV; HSV; EBV; HIV]
C - Viral Disease Organ Panels [CANS; Respiratory Exanthems; Myocarditis - Pericarditis
Enterocolitis]

III - FUNGAL INFECTIONS

A Cryptococcosis [AIDS; Hodgkins, NHLs; Leukemia;
Steroids; Diabetes]
Coccidioidomycosis
C. - Histoplasmosis
D - Actinomycosis
E - Nocarclosis
[Pneumonitis; lung abscess; brain abscess]
F - Blastomycosis
- Candidiasis [Diabetes; Immuno-compromised; IV catheter; Prosthetic heart valves; Antibiotic
abuse; AIDS; IV Drug abuse; Steroid therapy; Chemo#therapy; Lymphomas]
H - Aspergillosis
[I mm unocom promised; chronic asthma; pulmonary (anatomic abnormality of resp tract)]
I - Pneumocystis carinii [AIDS]
J - Zygomycosis [craniofacial; pulmonary; abdominal
- Sporotrichosis
IV - PARASITIC- INFECTIONS
A - Malaria
B - Leishmaniasis
C - Opportunistic free living Amoebae;
D - Amoebiasis [E.Histolytica]
E - Giardiasis
F - Coccidiosis [Cryptosporidium parvurn]
G - Microsporidia [Encep-halitozoonl/ Enterocytozoon]
H - Helminths
I - Trichinosis [Trichinella Spirallis]
J - Filariasis [Microfilariae]
K - Cysticercosis [Taenia solium]
L - Echinococcus [Hydatid cyst]
M - Schistosomiasis

V .SPIROCHAETAL INFECTIONS
A - Syphillis
B - Lyme disease [Bordelia Burgdorferi]
C – Leptospirosis

MINERAL/BONE DISORDERS

Mineral/Bone Disorders Panel - I

Mineral/Bone Disorders Panel -11
Bone Turn over Markers
Hypercalcaemia Panel - I
Hypercalcaemia Panel - II
Primary Hyperparathyroidism Panel - I
Primary Hyperparathyroidism Panel - II
Humoral Hypercalcaernia of Malignancy
Hypocalcaemia Panel - I
Hypocalcaemia Panel - II
Renal Osteodystrophy
Vit'D' Dependant Rickets
Hypoparathyroidism
Hypophosphatemia
Hypophosphatemia
Metabolic Bone Disorders
Primary Osteoporosis
Secondary Osteoporosis
Osteomalacia
Pagets Disease
Osteogenic Sarcoma
Metastatic Carcinoma

SKELETAL/MUSCLE DISORDERS
Skeletal Muscle Disease Panel - Basic
Muscular Dystrophies -Panel-I
Muscular Dystrophies -Panel - II
Polymyositis
Myopathies [endocrinal & alcoholic]
Malignant Hyperthermia [Heatstroke]
Myaesthenia Gravis

JOINT DISEASES
Arthritis Panel - I
Arthritis Panel - II
Synovial Fluid testing
Infective Arthritis
Rheumatoid Arthritis Panel I
Rheumatoid Arthritis Panel II
Gout

CANCER
I GASTROINTESTINAL TRACT

A. - Oral Cavity
Tongue Carcinoma
Salivary gland carcinoma
Oral cavity & cheek tumors

B - Stomach & duodenun

Oesophagus
Stomach & duodenum
Gastrinoma
Z. E. Syndrome

C Colon
Colorectal adenocarcinoma
Familial Adenomatous Polyposis colic
 Familial non polyposis colon cancer
D - Pancreas
Pancreatic Carcinoma
Glucagonoma
Insulinoma
Non islet cell Tumors
Pancreatic islet cell Tumors
E - Liver
Hepatocellular Carcinoma
Angiosarcoma liver
F - Spleen

II HEAD & NECK TUMORS

A - Retinoblastoma
B - Medullary Thyroid Carcinoma
C - Papillary & Follicular thyroid Carcinoma
D - Laryngeal Carcinoma

III ENDOCRINE TUMOR

A - Multiple Endocrine Neoplasia
B - Endocrine Pancreatic Tumors
C - Hypercalcaemia of Malignancy
D – Carcinoids

IV - LUNG CANCER
A - Adenocarcinomas
B - BronchogenicCarcinoma
C - Mesotheliomas
D - OAT (small cell) Carcinomas

E - Squamous cell Carcinomas

F - Pneumoconiosis related Carcinomas
V - FEMALE GENITAL TRACT
A - Ovarian Cancer
B - Uterine Cancer
C - Cancer Cervix
D - Gestational Tropho Elastic Tumors [Choriocarcinoma; Vesicular Mole etc]
E. - Breast Cancer

VI - MALE GENITAL TRACT

A - Prostate Cancer
B - Seminomas
C - Non Seminomatous Tumors
D - Teratomas

VII - URINARY TRACT

A - Blader Cancer
B - Renal Cell Carcinoma
C Wilms Tumor
D Adrenal Tumors

VIII - SKIN & ADNEXIAE

A - Melanoma
B - Skin Cancer

IX - VARIOUS TUMORS
A - Squamous Cell Cancers [Uterus; Cervix, lung; neck]
B - Carcinomas [general]
C - Bone Cancer [general]
D – Osteosarcoma
E - Soft Tissue Sarcoma
F - Mesothelioma

X - CNS CANCERS
A - CNS Tumors [general]
B- Astrocytoma
C - Neuroblastoma
D - Pituitary Tumors
E - Haemangioblastomas
F - Neurofibromatosis [type 1 & 11]
G -Schwannomas & Meningiomas

XI - HAEMOPOIETIC SYSTEM
A - Leukaemias (general)
B - Leukaemias - Chronic Myeloid
C - Leukaemias - Acute Lymphoid
D - Leukaemias - Acute Myeloid
ELymphomas[general]

PRENATAL & NEONATAL DIAGNOSIS

I - PRENATAL DIAGNOSIS
A - Prenatal Evaluation -Panel I [Maternal]
B - Prenatal Evaluation #Panel II [Maternal]
C - Prenatal Evaluation -Panel III [Fetal]
- Triple Marker Screen -Panel I
E - Triple Marker Screen -Panel ||
II - NEWBORN EVALUATION
A Follow up of suspected birth defects [ex. Downs; Mosiacism; Rh Isoimmunization; Metabolic
disorders; Intra uterine infections]
B Rh i soimmunization [Haemolytic disease of newborn]
C Neonatal Monitoring
Well baby newborn
Premature Infant (initial- management)
High risk infant
Neonatal Intensive Care
Neonatal Infections
III - INHERITED METABOLIC DISORDERS
A - Inherited Metabolic Disorders - Basic Panel #
I [screen]
- Inherited Metabolic Disorders - Basic Panel #
II [diagnosis]
C - Inherited Metabolic Disorders - Basic Panel #
III [specialized diagnosis]
- Carbohydrate
Disorders - Basic Panel I
E - Carbohydrate Disorders - Panel II
F - Glycogen Storage Diseases
- Galactosemia
H - Amino acid Disorders -Panel I
I - Amino acid Disorders -Panel II
J - Phenylketonuria
K - Homocysteinuria [Homocysteinemia]
L - Lysosomal Storage Disorders - Panel I
M - Lysosomal Storage Disorders - Panel II
N - Gauchers Disease
0 - Niemann - Pick Disease
P - Tay Sach's Disease
Q - Porphyries - Panel I
R - Porphyries - Panel II
S - Acute Intermittent Perphyria
T - Hereditary Coproporphyria
U - Variegate Porphyria
V - Erythropoetic Protoporphyria
W - Porphyria Cutanea Tarda

GENERAL

PLASMA PROTEIN ELECTROPHORESIS

A - Electrophoresis - Basic Panel I [major plasma proteins]
B - Plasma Proteins Panel 11
C Electrophoresis [Ascites/Edema]
D Electrophoresis [Cirrhosis/CAH]

E - Electrophoresis
[Monoclonal gammopathy]
F - Electrophoresis
[Unexplained Proteinuria]
G - Electrophoresis [Acute
phase response]
H - Electrophoresis
Immunodeficiencies
I - Electrophoresis
[Lymphomas: CLL]
K - Electrophoresis
Collagen diseases

II – MISCELLANEOUS DISORDERS

A- Sarcoidosis
B – Amyloidosis
C – Lead Poisoning

III – GENERAL PANELS

A General health
B Basic Metabolic Panel
C Comprehensive Metabolic panel
D Coma
E Transplant