Category Archives: Clinical Practice

Blogs about patient care and related issues

DATA COLLECTION THROUGH INVESTIGATIONS

This article is still in the process of being written.

Importance of Investigations Data

In addition to information gathered during the process of clinical data gathering, further data collection is accomplished through:

  1. Investigations
  2. Monitoring and observations
  3. Progress review (interview and examination)

In general, further information obtained from investigations is required to:

  1. Determine or clarify the diagnosis
  2. Add further details to the patient profile
  3. Monitor progress of the illness
  4. Monitor effects of whatever early treatment that has been given

Value of Various Types of Investigations

In general, investigations provide data that is objective i.e. more accurate and specific. The information gained can disclose general aspects of the health of the patient or specific changes relating to the disease affecting him/her. Tests that give specific information concerning a disease are used to clarify the diagnosis and are called diagnostic investigations. Usually, diagnosis becomes increasingly more accurate when investigation results clarify the change in morphology (shape, size, depth) and pathophysiology (alteration of function) brought about by the disease.

Tests also help the care-giver to understand the health status of the patient including preexisting health problems and those associated with the disease.

For monitoring progress of the disease and effects of treatment, investigations are repeated so as to detect variations in their values over time. This can be used as the criteria to help indicate:

    1. disease improvement or deterioration
    2. effectiveness of the treatment
    3. occurrence of adverse effects of treatment

Modalities Used for Investigation

Various technology or modalities are used for investigations. They include:

      1. Imaging studies
        1. Radiology
        2. Radio-isotope Scans
      2. Laboratory tests
        • Biochemistry
        • Immunology
        • Microbiology
        • Haematology
        • Histopatholgy, Cytology and Cytogenetics
      3. Endoscopic examination
      4. Tests of Physiological Function

Salient Features of Various Modalities

Imaging Studies

Imaging studies make it possible for the clinician to detect changes in morphology (anatomy) of regions and organs caused by disease and in doing so indicate the location and extent of the disease. These changes in appearance include variation in size, shape and extent or the appearance of something unusual (a lesion). The information  can point to the organ or tissue involved by the disease, the probable pathology and also show how far the disease has spread. Some examinations may also demonstrate variations in function. Examples include flouroscopy, contrast studies, ultrasound, Doppler ultrasound angiography and radio-isotope studies.

Repeat imaging tests can be used for re-assessment of the progress of the disease by detecting the variation in morphology and function over time.

Laboratory Tests

Biochemical tests are used mainly to determine

  • the status of physiological functions
  • presence of abnormal cells or tissue
  • appearance of an abnormal chemical, cells or material (e.g. markers, abnormal products of metabolism, casts in the urine etc.)

Abnormal results can point to the degree of change in the activity of certain organs or systems. When the results of initial tests performed are taken together with symptoms and signs the data can point to the provisional diagnosis of a certain syndrome. The diagnosis help indicate what further tests need to be done.

Immunology tests are capable of providing specific results. The presence of antigens and antibodies may indicate a certain disease or disease group. Often immunology tests need to be repeated to see a rise in the titre hence demonstrating an active or evolving disease. Immunoassays are useful to detect presence of certain disease causing agents or products of the disease when they are present in very small amounts including microorganisms, antibodies and other proteins produced by the body in response to a disease.

Microbiology tests are used to detect the presence and identification of microorganisms (bacteria, fungi and virus) via direct microscopy, culture and special tests on the organism grown. The tests are done on various body fluids and tissue. Positive results are often diagnostic. Because it is often difficult to detect or grow microorganisms, negative tests may or may not exclude a disease.

Haematology are tests done on blood, bone-marrow or fluids where blood is present. It can indicate changes in the composition, alteration in morphology of cells and presence of abnormal cells. Changes in composition and morphology gives syndromic diagnosis such as anaemia, polycythemia, agranulocytosis, neutropenia and pancytopenia. They make it possible for the clinician to think of various differential diagnosis.  Presence of abnormal cells are often diagnostic.

Histopatholgy, Cytology and Cytogenetics are tests on tissue or cells often taken through biopsy or after surgical removal of an organ or part of it. The tissue or cells are made to react with certain chemicals (stains) or markers and exmianed under the microscope. Deviation from normal of the tissue structure, the changes in the cells themselves and the extent of spread are looked for. Their findings are often diagnostic

Endoscopic Examination

Endoscopy is the technique of viewing the internal surface of various hollow organs (the mucosa or endothelium) either directly or using a miniature camera. It provides the means to determine the changes in shape, contour, texture and other morphologic changes. The views can be characteristic of a disease. Via endoscopy, biopsies can be taken for Histopatholgy and Cytology examinations which can then  provide a definite diagnosis.

Video or photographs of endoscopic pictures can be kept and used to compare with subsequent examinations for purposes of monitoring and reevaluation.

Tests of Physiological Function

Many tests have been developed to demonstrate the functions of various organs or physiologic systems. These include:

    • Pulmonary (lung) function tests
    • Tests of cardiac function
    • Neuromuscular function tests
    • Neurologic tests
    • Hearing tests (Audiometry)
    • Vision tests (Optometry)

Most of these tests are repeatable making them useful for assessment of progress of a function or disease.

Initial Investigations

Initial investigations may be ordered at the time of initial clinical data gathering or slightly later mainly to:

  1. Clarify the diagnosis
  2. Add further details to the patient profile

A particular investigations may be useful for one or both purposes.

Investigations to Clarify the Diagnosis

After the initial clinical data gathering, the diagnosis reached is often of a low-level of accuracy i.e. either a symptom complex or a syndrome. Nevertheless, it provides a pointer to the possible differential diagnosis. The clinician will use the differential diagnosis to decide on the appropriate investigations to perform in order to obtain objective data to narrow down the diagnosis.

Commonly available and relatively simple and inexpensive investigations are usually performed first and may also be done as a routine. Some are available at the clinical work place itself (the point of care). Subsequently, the clinician will order the more specific tests as indicated by the information obtained.

However if, based on history and physical findings the likelihood of a particular diagnosis is high, tests that give fairly specific hence diagnostic results can be ordered. Indeed, where indicated (especially in an emergency), it is not necessary to wait for results of general (routine) tests before performing special complicated tests if such tests would hasten the diagnosis.

Investigations that Add Further Details to the Patient Profile

To know the health profile of a patient in more detail, information from clinical data gathering (by interview and physical examination) can be augmented by investigations. Often certain basic investigations are performed routinely for this purpose. The purpose is to detect :

  1. the presence of certain  diseases common among the demographic or social group that the patient belongs to
  2. the effects of the current illness on various body systems

This more complete health profile will allow the care provider to anticipate various needs of the patient and provide comprehensive care.

Investigations to Determine the Diagnosis with Certainty

Usually, diagnosis becomes increasingly more accurate as more investigations are done. When the initial investigations point to the possibility of a certain diagnosis, the relevant specific investigations are performed. The clinician can then use the results to determine a diagnosis with a high level of accuracy. Hence, at the beginning, investigations can help the clinician make a diagnosis as syndrome or disease class i.e. together with the symptoms and signs link it to a body system (anatomic and physiologic) or aetiology. Specific investigations make it possible for the clinician to ascertain the diagnosis as a specific disease.

Investigations that Are Diagnostic

Definitive diagnosis is one with a high degree of probability/accuracy because adequate, accurate and pertinent data are available. Usually, the additional more accurate data are derived from or are arrived at from the:

  1. Results of investigations and diagnostic procedures including imaging studies, specific biochemical or immunological tests, demonstration of presence of a particular microorganism and cytological or histopathological examination of diseased tissues
  2. Improved view or access e.g. from endoscopy, examination under anesthesia or surgical exposure
  3. Subsequent emergence of characteristic patterns of symptoms or signs during observation
  4. Response to specific treatment

Quite often certain simple investigations can be used to make an accurate diagnosis. This occurs when findings of the tests are peculiar to the disease.

Usually it is the more complex investigations that can be the basis for making a diagnosis with a high level of certainty. Yet at other times it is the combination of information from various tests by satisfying a set of criteria is used to make a definite diagnosis.

Positive and Negative Results

A test is useful if it can pick up an abnormality it is supposed to detect. A positive result is when the variation from normal or presence of an abnormal substance is detected. A test result is said to be negative if what is being tested is not found or the result is within normal limits. A result can turn out to be negative if the  quantity of substance looked for is too small or if the test is not performed correctly. Sometimes it may be necessary to repeat tests with negative results.

Sensitivity

A sensitive test would detect an abnormality easily. If a test is not very sensitive it would fail to provide a positive result in some cases. However, in a very sensitive test, a positive result may not mean that the patient has the disease (false positive). Often because of this tests are performed in two steps. A fairly sensitive (usually less expensive or complicated) test is used first and a second more specific test is done if the result of the former is positive.

Specificity

To be diagnostic, a test should only be positive in patients having that particular disease i.e. it is specific to the disease. Some tests may be positive in cases that do not actually have the disease. In that case, it acts as a screening test, a more specific test need to be done or the clinician should consider the result together with data from other tests or other sources.

Usefulness of Tests of Various Modalities for Diagnosis

 Biochemical Tests

For example Serum Amylase or Lipase is diagnostic of Acute pancreatitis, direct microscopy of a stained slide of pus may be diagnostic for Gonorrhea.

Immunoassays

Immunoassays are used to identify different proteins, hormones and antibodies in blood, urine or other body fluids. The test is based on the reaction of an antigen with an antibody. Antibodies together with suitable  markers are usually used as reagents to detect the protein or other molecules (analyte) present in the patient. In some instances, an antigen may also be used as the reagent.

If Monoclonal antibodies i.e. those that are specific to a particualr antigen looked for is used then the presence or abscence of the antigen is usually diagnostic.

Microbiology

Imaging Studies

Spontaneous pneumothorax is diagnosed based on a plain chest x-ray.

Endoscopy

Physiological tests

Use of Investigation for Monitoring Reassessment and Reevaluation

Monitoring is the performance and documentation of planned serial measurements at regular intervals. These information and results are interpreted by comparing them with the condition at the first visit to determine progress. A target measure can also be set to determine whether the treatment objectives are being met. Test of function and levels of certain parameters may be used to anticipate and detect side effects of treatment.

Many of these tests are done regularly and charted on a table or graph. The use of a Laboratory Information System (LIS) is useful for this purpose. Trends can then be discerned. The frequency of measurement of parameters used for monitoring and evaluation selected depends on:

  1. Nature of the parameter in terms of how rapidly discernible changes occurs
  2. Desirability (benefit), efficiency and cost effectiveness

Even complex tests such as Microbiological, Hematological tests, Imaging studies and endoscopy may be repeated at planned intervals or when certain events occur. They are useful in evaluating the progress of the disease especially in response to treatment. The findings can help the clinician in deciding to continue, change or cease treatment.
Radiological studies and radioisotope scans (e.g. PET CT) are often repeated to determine progress. Due consideration need to be given to cumulative exposure to radiation. Ultrasound examinations are very suitable for monitoring and evaluation because tehy are relatively easy to do, safe and inexpensive. The ability to store images and retrieve them for comparison is made easy by the use of Radiology Information system (RIS) and PACS system.
Video or photographs of endoscopic captured during sequential examinations can be compared to determine healing or spread.

Images of histologic and cytologic slides before treatment (biopsies) and after treatment (surgical specimen or re-biopsy) can also be compared.

The Basis of Patient Care

The subject of clinical work process and total patient care is not covered well in most textbooks dealing with clinical methods or medicine in general. Medical students somehow acquire an understanding of the approach to patient care despite (in my opinion) an incoherent exposition to the subject.

A search via the internet result in a fairly long list of articles  and posts but few if any describe exactly the processes of patient care. It would appear that understanding of it is assumed.  The term process as applied in other industrial endeavors is seldom used in medical circles except when discussing quality management and clinical information systems.

Actually, clinical work processes in the guise of Nursing Process is very familiar to nurses. Unfortunately, it is considered as a special technique rather than something more fundamental. The current feeling is that “Nursing Process” has been superceded by “Nursing Care Plan”.

In practice, the method of caring for patients and their disease guided by a standard sequence of clinical processes is used by all direct care providers (clinicians) be they doctors, nurses, physiotherapists, occupational therapists, speech therapists, nutritionists, counselors, and clinical psychologists. Currently in some instances, optometrists and audiometrists are also care practitioners (manage some patients on their own) and would therefore be guided by the same processes.

You can read my article about this subject entitled “Overview of Clinical Care“.

Abdollah Salleh