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Malaria,Causes,Exams and Tests,Symptoms

 Malaria

 Mosquito, Adult Feeding on the Skin      Malaria, Microscopic View of Cellular Parasites

Causes

 Malaria is caused by a parasite that is passed from one human to another by the bite of infected Anopheles mosquitoes. After infection, the parasites (called sporozoites) travel through the bloodstream to the liver, where they mature and release another form, the merozoites. The parasites enter the bloodstream and infect red blood cells.
The parasites multiply inside the red blood cells, which then break open within 48 to 72 hours, infecting more red blood cells. The first symptoms usually occur 10 days to 4 weeks after infection, though they can appear as early as 8 days or as long as a year after infection. The symptoms occur in cycles of 48 to 72 hours.
Most symptoms are caused by:
  • The release of merozoites into the bloodstream
  • Anemia resulting from the destruction of the red blood cells
  • Large amounts of free hemoglobin being released into circulation after red blood cells break open
Malaria can also be transmitted from a mother to her unborn baby (congenitally) and by blood transfusions. Malaria can be carried by mosquitoes in temperate climates, but the parasite disappears over the winter.
The disease is a major health problem in much of the tropics and subtropics. The CDC estimates that there are 300-500 million cases of malaria each year, and more than 1 million people die from it. It presents a major disease hazard for travelers to warm climates.
In some areas of the world, mosquitoes that carry malaria have developed resistance to insecticides. In addition, the parasites have developed resistance to some antibiotics. These conditions have led to difficulty in controlling both the rate of infection and spread of this disease.
There are four types of common malaria parasites. Recently, a fifth type, Plasmodium knowlesi , has been causing malaria in Malaysia and areas of southeast Asia. Another type, falciparum malaria, affects more red blood cells than the other types and is much more serious. It can be fatal within a few hours of the first symptoms.

Symptoms

Exams and Tests

During a physical examination, the doctor may find an enlarged liver or enlarged spleen. Malaria blood smears taken at 6 to 12 hour intervals confirm the diagnosis.
A complete blood count (CBC) will identify anemia if it is present.

Treatment

Malaria, especially Falciparum malaria, is a medical emergency that requires a hospital stay. Chloroquine is often used as an anti-malarial medication. However, chloroquine-resistant infections are common in some parts of the world.
Possible treatments for chloroquine-resistant infections include:
  • The combination of quinidine or quinine plus doxycycline, tetracycline, or clindamycin
  • Atovaquone plus proguanil (Malarone)
  • Mefloquine or artesunate
  • The combination of pyrimethamine and sulfadoxine (Fansidar)
The choice of medication depends in part on where you were when you were infected.
Medical care, including fluids through a vein (IV) and other medications and breathing (respiratory) support may be needed.

Outlook (Prognosis)

The outcome is expected to be good in most cases of malaria with treatment, but poor in Falciparum infection with complications.

Possible Complications

When to Contact a Medical Professional

Call your health care provider if you develop fever and headache after visiting the tropics.

Prevention

Most people who live in areas where malaria is common have gotten some immunity to the disease. Visitors will not have immunity, and should take preventive medications.
It is important to see your health care provider well before your trip, because treatment may need to begin as long as 2 weeks before travel to the area, and continue for a month after you leave the area. In 2006, the CDC reported that most travelers from the U.S. who contracted malaria failed to take the right precautions.
The types of anti-malarial medications prescribed will depend on the area you visit. According to the CDC, travelers to South America, Africa, the Indian subcontinent, Asia, and the South Pacific should take one of the following drugs: mefloquine, doxycycline, chloroquine, hydroxychloroquine, or Malarone. Even pregnant women should take preventive medications because the risk to the fetus from the medication is less than the risk of catching this infection.
People who are taking anti-malarial medications may still become infected. Avoid mosquito bites by wearing protective clothing over the arms and legs, using screens on windows, and using insect repellent.
Chloroquine has been the drug of choice for protecting against malaria. But because of resistance, it is now only suggested for use in areas where Plasmodium vivax , P. oval , and P. malariae are present. Falciparum malaria is becoming increasingly resistant to anti-malarial medications.
For travelers going to areas where Falciparum malaria is known to occur, there are several options for malaria prevention, including mefloquine, atovaquone/proguanil (Malarone), and doxycycline.
Travelers can call the CDC for information on types of malaria in a certain area, preventive drugs, and times of the year to avoid travel. See: 

References

Fairhurst RM, Wellems TE. Plasmodium species (Malaria). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases . 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 275.
Krogstad DJ. Malaria. In: Goldman L, Ausiello D, eds. Cecil Medicine . 23rd ed. Philadelphia, Pa: Saunders Elsevier. 2007:chap 36

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Hematology examination

Hematology Studies
Test: Total Hemoglobin (Hgb or Hb)
A test used to determine the amount of hemoglobin in the blood. Hgb is the pigment part of the erythrocyte, and the oxygen-carrying part of the blood.
Normal Values:
males: 12-17 grams/100ml
females: 11-15 grams/100ml
Clinical Implications:
A Low hemoglobin level indicates anemia. Estimates of Hgb in each RBC are moderately important when determining the total blood Hgb. However, hemoglobin findings are even more dependent upon the total number of RBC's. In other words, for the diagnosis of anemia, the number of RBC's is as important as the hemoglobin level.
Blood hemoglobin level has become a "routine" lab test for most patients admitted to hospitals today. Hgb is obviously important for the diagnosis of anemia and hemorrhage. It is equally important for diagnosing many lesser known diseases.
The test can be performed upon capillary blood, such as drawn from the finger stick. The test is often performed along with other tests, thereby requiring a larger specimen of blood, as from venipuncture. Hemoglobin in the body is dependent upon amounts of iron. A lack of available iron causes one type of anemia, due to the reduced production of hemoglobin. Remember that in the strictest sense, anemia is not in itself a diagnosis, but rather a symptom that there is something else wrong in the body. For example, malnutrition (low iron levels), would be the diagnosis of the patient, not just the anemia. The secondary diagnosis would be anemia, but malnutrition must be treated in order to "cure" the anemia.
*Note--Fetal Hemoglobin:
Fetal Hb (Hb F), is a normal Hb product in the red blood cells of a fetus and in smaller amounts in infants. It constitutes 50% to 90% of Hb in a newborn; the remaining Hb consists of Hb A1 and Hb A2 the Hb in adults.
Under normal conditions, the body ceases to manufacture fetal Hb sometime during the first year of life, and from that point on manufactures adult Hb. If this changeover does not occur and fetal Hb continues to constitute more than 5% of the Hb after age six months, an abnormality should be suspected, particularly thalassemia.
VARIATIONS OF HEMOGLOBIN TYPE AND DISTRIBUTION (in adults)
Percentage of total Hemoglobin hemoglobin Clinical Implications

Hb A 95% to 100% Normal
Hb A2 4% to 5.8% b-thalassemia minor
  1.5% to 3% b-thalassemia major
  Under 1.5% b-d-thalassemia minor
Hb F Under 2% Normal
  2% to 5% b-thalassemia minor
  10% to 90% b-thalassemia major
  5% to 15% b-d-thalassemia minor
  5% to 35% Heterozygous hereditary Persistence of fetal Hb (HPFH)
  100% Homozygous HPFH
  15% Homozygous Hb S
Homozygous Hb S 70% to 98% Sickle Cell disease
Homozygous Hb C 90% to 98% Hb C disease
Heterozygous Hb C 24% to 44% Hb C trait
Test: Hemoglobin Electrophoresis
Hemoglobin electrophoresis is probably the most useful laboratory method for separating and measuring normal and some abnormal Hb. Through electrophoresis, different types of Hb are separated to form a series of distinctly pigmented bands in a medium (cellulose acetate or starch gel). Results are then compared with those of a normal sample.
Hb A (same as Hb A1), Hb A2, Hb S, Hb C, and Hb F are routinely checked, but the laboratory may change the medium or its pH to expand the range of the test. This test, by measuring the different types of Hb, is used to detect normal and abnormal types of hemoglobin, to aid in the diagnosis of thalassemia, and to aid in the diagnosis of sickle cell disease or trait.
**For normal or reference values, see the chart above.
Test: Hematocrit Hct
The hematocrit measures percentage by volume of packed red blood cells in a whole blood sample. For example, a HCT of 40% indicates that a 100-ml sample of blood contains 40 ml of blood cells. Packing is achieved by centrifuging anticoagulated whole blood in a capillary tube so that the cells are tightly packed without hemolysis.
Normal Values:
males: 40 to 50 percent
females: 37 to 47 percent
Clinical Implications:
Two small specimens of blood are obtained and compared. They are the same amount of blood exactly. One specimen is then centrifuged and subsequently compared to the first specimen. A percentage is then obtained from that comparison. This comparison is the hematocrit, Hct. The value of the hematocrit is dependent upon the number of RBC's. If the Hct is abnormal, then the RBC count is possibly abnormal. If the RBC count turns out to be normal, then the average size of the RBC is probably too small. Shock, hemorrhage, dehydration, or excessive IV fluid administration can reduce the Hct.
As you can see, there are many factors which can influence the results of the hematocrit test. However, this is still a good baseline lab test for the patient. It helps the physician to diagnose and to treat the patient with any disease which will lower or raise the Hct levels.
Test: Red Blood Cell Count RBC count
A count of actual (or estimated) number of RBC's per cubic mm of whole blood.
Normal Values:
males: 4.5 to 6.0 million/cu mm blood
females: 4.0 to 5.5 million/cu mm blood
Clinical Implications:
The RBC count is useful for determining such problems as anemia and hemorrhage. In combination with other hematology tests, it can be quite useful for diagnosis. This test can also give an indirect estimate of the hemoglobin levels in the blood. RBC's are actually "Red Blood Corpuscles," (non-nucleated cells). The term corpuscle indicates that it is a mature Red Blood Cell. Once the immature cell has matured, it is then, and only then, capable of carrying oxygen. It is then also not "technically" a cell anymore. Once it has matured, it loses its nucleus and can no longer be properly termed a cell. It would be called a corpuscle. However, everyone still refers to them as RBC's (cells). The source of the specimen is whole blood, capillary, or venous blood.
Test: Red Cell Indices (Wintrobe Indices)
A report of the individual characteristics of the RBC. The following are those characteristics which are used to indicate anemia. If abnormal findings are present, the anemias can be defined as macrocytic, microcytic, hypochromic, others. When this is discovered, the exact cause of the anemia can be determined more easily.
The following are all part of indices:
  1. MCV
  2. MCH
  3. MCHC
1. MCV - Mean Corpuscular Volume
The volume of the average RBC
calculated by:
 Hct x 10  = MCV
# of RBC's
Normal Value: 80-94 u3 (cubic microns)
Clinical Implications:
The MCV indicates the relative size of the RBC's. It does not indicate anything else about the cell. Several different types of anemias can be classified as micro- or macrocytic anemias. This test can direct the MD toward those types of anemias which alter the MCV results.
  1. microcytic anemia.......decreased MCV (small cells)
  2. macrocytic anemia.......increased MCV (large cells)
2. MCH - Mean Corpuscular Hemoglobin: (Weight of hemoglobin in each cell)
calculated by:
 Hgb x 10  = MCH
# of RBC's
Normal Value: 27-31 uuGrams (micro micro Grams)
3. MCHC - Mean Corpuscular Hemoglobin Concentration
Concentration of hemoglobin in the average RBC
calculated by:
Hgb x 10 = MCHC
 Hct
Clinical Implications:
The MCHC is dependent upon the size of the RBC as well as the amount of hemoglobin in each cell. Certain diseases and anemias will alter the RBC count and/or the amount of hemoglobin in the cell. The MCHC is not as dependent upon the RBC count as the other tests in this section. Therefore, the MCHC can be useful for the diagnosis of such conditions which are not dependent upon the number of RBC's.
The nursing implications for these tests are numerous. To the nurse, most cases of anemia are quite apparent. They are caused by hemorrhage, malnutrition, etc. However, the Indices can be used to help diagnose the less common types of anemias. Nursing care will then be determined according to the needs of that particular patient.
Test: Reticulocyte Count (Retic count)
This is a test for the estimation of the actual numbers of reticulocytes in the blood. Reticulocytes are the immature RBC's.
Normal Values: approx 1% of normal RBC count (50,000); Results vary; range 0.5% to 1.5%
Clinical Implications:
The retic count is an indication of the production of RBC's by the bone marrow. An increase from the normal, usually indicates the body is responding to such pathologies as hemorrhage, anemia, hemolysis, or other such disease process. Decreased retic count may be indicative of aplastic anemia or any related disease.
The retic count is also examined for those persons working near any type of radioactive materials. The nurse should remember that the body tries to compensate for such conditions as the hemolytic and macrocytic conditions mentioned above. A large number of retics will be seen after the treatment has begun for pernicious anemia, in which large numbers will be produced as an attempt to bring to maturity, large numbers of RBC's.
Test: Sickle Cell Test
The sickle cell test, also known as the Hb S test, is used to detect sickle cells, which are severely deformed, rigid erythrocytes that may slow blood flow. Sickle cell trait (characterized by heterozygous Hb S) is found almost exclusively in people of African ancestry. It is present in nearly 8% of African Americans.
Although this test is useful as a rapid screening procedure, it may produce erroneous results. Hb electrophoresis should be performed to confirm the diagnosis if sickle cell disease is strongly suspected.
**See Hemoglobin electrophoresis test earlier in this chapter.
Test: Iron and Total Iron-binding Capacity
Iron is essential to the formation and function of hemoglobin, as well as many other heme and nonheme compounds. After iron is absorbed by the intestine, it is distributed to various body compartments for synthesis, storage, and transport. Serum iron concentration is normally highest in the morning and declines progressively during the day. Thus, the sample should be drawn in the morning.
An iron assay is used to measure the amount of iron bound to transferrin in blood plasma. Total iron-binding capacity (TIBC) measures the amount of iron that would appear in plasma if all the transferrin were saturated with iron.
Serum iron and TIBC are of greater diagnostic usefulness when performed with the serum ferritin assay, but together, these tests may not accurately reflect the state of other iron compartments, such as myoglobin iron and the labile iron pool. Bone marrow or liver biopsy, and iron absorption or excretion studies may yield more information.
Normal Values:
Serum Iron:
males: 50 to 150 u/g/dl
females: 35 to 145 ug/dl
TIBC, Total Iron-binding capacity:
males and females: 250 to 400 ug/dl
Saturation:
males and females: 14% to 50%
Test: Ferritin
Ferritin is a major iron-storing protein found in reticuloendothelial cells. It normally appears in small quantities in serum. In healthy adults, serum ferritin levels are directly related to the amount of available iron stored in the body and can be measured accurately by radioimmunoassay.
Normal Values:
Men: 20 to 300 NG/ml
Women: 20 to 120 NG/ml
6 mo to 15 yr 7 to 140 NG/ml
2 to 5 months 50 to 200 NG/ml
1 month old 200 to 600 NG/ml
Neonates 25 to 200 NG/ml
Normal serum Ferritin values will vary with age. Remember to check with your lab, as normal values may be different in different labs. The blood is collected via venipuncture in a standard 10-ml red-top tube. A random blood specimen is used. No special instructions need to be given to the patient except for explaining the procedure. Recent blood transfusions may elevate serum ferritin levels.
Increased Serum Ferritin Levels: may indicate acute or chronic hepatic disease, iron overload, leukemia, acute or chronic infection or inflammation, Hodgkin's Disease, or chronic hemolytic anemias.
Slight increase, or normal Ferritin Level: may indicate chronic renal disease
Decreased serum Ferritin Levels: may indicate chronic iron deficiency
Test: ESR--Erythrocyte Sedimentation Rate
The ESR measures the time required for erythrocytes from a whole blood sample to settle to the bottom of a vertical tube. Factors influencing the ESR include red cell volume, surface area, density, aggregation, and surface charge. The sample must be examined within 2 hours of collection and it must be handled gently, no clotting of sample must take place.
Normal values: 0-20 mm/hr (gradually increase with age)
The ESR is a sensitive, but nonspecific test that is frequently the earliest indicator of disease. It often rises significantly in widespread inflammatory disorders due to infection or autoimmune mechanisms. Such elevations may be prolonged in localized inflammation and malignancies.
Increased ESR: may indicate pregnancy, acute or chronic inflammation, tuberculosis, rheumatic fever, paraproteinemias, rheumatoid arthritis, some malignancies, or anemia.
Decreased ESR: may indicate polycythemia, sickle cell anemia, hyperviscosity, or low plasma protein.
Test: Osmotic Fragility
Osmotic fragility measures red blood cell (RBC) resistance to hemolysis when exposed to a series of increasingly dilute saline solutions. The sooner hemolysis occurs, the greater the osmotic fragility of the cells.
Purpose of test - The purpose of this test is to help diagnose hereditary spherocytosis and to supplement a stained cell examination to detect morphologic RBC abnormalities.
Normal results: Osmotic fragility values (percentage of RBC's hemolyzed) are determined by the tonicity of the saline. Reference values for the different tonicities are as follows:
0.5 g/dl sodium chloride (NaCl) solution (unincubated)
males: 0.5% to 24.7% hemolysis
females: 0% to 23.1% hemolysis
0.6 g/dl sodium chloride solution (incubated)
males: 18% to 55.2% hemolysis
females: 2.2% to 59.3% hemolysis
0.65 g/dl sodium chloride solution (incubated)
males: 4% to 24.8% hemolysis
females: 0.5% to 28.9% hemolysis
0.75 g/dl sodium chloride solution (incubated)
males: 0.5% to 8.5% hemolysis
females: 0.1% to 9.3% hemolysis
Low osmotic fragility (increased resistance to hemolysis) is characteristic of thalassemia, iron deficiency anemia, and other red blood cell disorders in which codocytes (target cells) and leptocytes are found. Low osmotic fragility also occurs after splenectomy.
High osmotic fragility (increased tendency to hemolysis) occurs in hereditary spherocytosis, in spherocytosis associated with autoimmune hemolytic anemia, severe burns, chemical poisoning, or in hemolytic disease of the newborn (erythroblastosis fetalis).
Test: WBC count--White Blood Cell Count (Leukocyte count)
A laboratory test that counts the actual number of WBC's in the blood.
Normal Values: total WBC: 4,500 to 10,500
BASIC TYPES OF WBC'S:
  • neutrophils (granulocyte)
  • lymphocytes (non-granulocyte)
  • monocytes (non-granulocyte)
  • eosinophils (granulocyte)
  • basophils (granulocyte)
Clinical Implications:
As we all know, WBC's are our body's first line of defense against invading bacteria and most other harmful organisms. This test (WBC), measures the total number of all types of WBC's. Further examination of the different types and numbers of cells present, could tell much about the state of the body's defense system. WBC count will normally vary as much as 2,000 on any given day.
Test: Differential Cell Count also known as "diff" or "differential"
Laboratory test that counts actual numbers of different types of WBC's.
Clinical Implications:
The following chart gives the normal values for each type of WBC. Interpretation of the results of the differential must always be done with the total number of WBC's in mind.
The WBC differential evaluates the distribution and morphology of white blood cells. Therefore, it provides more specific information about a patient's immune system than the WBC count alone. In the differential test, the lab classifies 100 or more white cells in a stained film of peripheral blood according to two major types of leukocytes. They are: (1) Granulocytes (neutrophils, eosinophils, basophils); (2) non-Granulocytes (lymphocytes, monocytes). The percentage of each type is then determined.
The differential count is the relative number of each type of white cell in the blood. By multiplying the percentage value of each type, by the total WBC count, the lab obtains the absolute number of each type of white cell. Although little is known about the function of eosinophils in the blood, abnormally high levels of them are associated with various types of allergic disorders and reactions to parasites. In such cases, the eosinophil count is sometimes ordered as a follow-up to the white cell differential. This test is also appropriate if the differential WBC count shows a depressed eosinophil level.
Interpreting the Differential
In order to interpret the results of the WBC and the Differential, the nurse must consider both relative and absolute values of the differential. Considered alone, relative results may point to one disease while masking the true pathology that would be revealed by considering the results of the white cell count.
For example, consider a patient whose white blood cell (WBC) count is 6000/ul and whose differential shows 30% neutrophils and 70% lymphocytes. His relative lymphocyte count would seem to be quite high (lymphocytosis), but when this figure is multiplied by his white cell count (6000 x 70% = 4,200 lymphocytes/ul), it is well within normal range.
The patient's neutrophil count, however, is low (30%), and when this is multiplied by the white cell count (6,000 x 30% = 1,800 neutrophils/ul), the result is a low absolute number. This low result indicates decreased neutrophil production, which may mean depressed bone marrow.
CELL ADULT ABSOLUTE RELATIVE VALUE (6-18 years old)
TYPE VALUE VALUE BOYS GIRLS

Neutrophils 47.6% to 76.8% 1,950 to 8,400/ul 38.5% to 71.5% 41.9% to 76.5%
Lymphocytes 16.2% to 43% 660 to 4,600/ul 19.4% to 51.4% 16.3% to 46.7%
Monocytes 0.6% to 9.6% 24 to 960/ul 1.1% to 11.6% 0.9% to 9.9%
Eosinophils 0.3% to 7% 12 to 760/ul 1% to 8.1% 0.8% to 8.3%
Basophils 0.3% to 2% 12 to 200/ul 0.25% to 1.3% 0.3% to1.4%
NEUTROPHILS:
Increased by:
  • Infection; gonorrhea, osteomyelitis, otitis media, chickenpox, herpes, others
  • Ischemic necrosis due to MI, burns, carcinoma
  • Metabolic Disorders; diabetic acidosis, eclampsia, uremia, thyrotoxicosis
  • Stress Response; due to acute hemorrhage, surgery, emotional distress, others
  • Inflammatory disease; rheumatic fever, acute gout, vasculitis, myositis
Decreased by:
  • Bone marrow depression; due to radiation or cytotoxic drugs
  • Infections; such as typhoid, hepatitis, influenza, measles, mumps, rubella
  • hypersplenism; hepatic disease, storage disease
  • Collagen vascular disease; systemic lupus erythematosus
  • Deficiency of; folic acid or vitamin B12
EOSINOPHILS:
Increased by:
  • Allergic disorders; asthma, hay fever, food or drug sensitivity, others
  • Parasitic infections; trichinosis, hookworm, roundworm, amebiasis
  • Skin Diseases; eczema, psoriasis, dermatitis, herpes, pemphigus
  • Neoplastic diseases; Hodgkin's disease, chronic myelocytic leukemia
  • Miscellaneous; collagen vascular disease, ulcerative colitis, pernicious anemia, scarlet fever, excessive exercise, others
Decreased by:
  • Stress response; due to trauma, shock, burns, surgery, mental distress, Cushing's Syndrome
BASOPHILS:
Increased by:
  • Miscellaneous disorders; Chronic myelocytic leukemia, polycythemia vera, some chronic hemolytic anemias, Hodgkin's disease, myxedema, ulcerative colitis, chronic hypersensitivity states,
Decreased by:
  • Miscellaneous disorders; hyperthyroidism, ovulation, pregnancy, stress
LYMPHOCYTES:
Increased by:
  • Infections; pertussis, syphilis, tuberculosis, hepatitis, mumps, others
  • Others; thyrotoxicosis, hypoadrenalism, ulcerative colitis, immune diseases
Decreased by:
  • Severe debilitating illness; congestive heart failure, renal failure, advanced tuberculosis
  • Others; Defective lymphatic circulation, high levels of adrenal Corticosteriods, others
MONOCYTES:
Increased by:
  • Infections; subacute bacterial endocarditis, tuberculosis, hepatitis, malaria
  • Collagen vascular disease; systemic lupus erythematosis, rheumatoid arthritis
  • Carcinomas; monocytic leukemia, lymphomas
Decreased by: (unknown)
HEMATOLOGY................In Summary
RBC lab values, along with the indices, are used to diagnose anemia and to define the type of anemia present. The lab values are calculated and compared for the individual characteristics of the blood cells.
When the individual characteristics of the cells are determined, you can then decide if the condition is hemorrhagic or another type of anemia.
One should ask the following questions in order to isolate the type of anemia:
  1. Are the reticulocytes increased?
    possible hemorrhage


  2. Is the hemoglobin abnormal?
    possible factor anemia
    possible hemorrhage


  3. Is the RBC normal?
    possible metastatic problem
    possible hemorrhage
Coagulation Studies
Nursing implications related to clotting studies are numerous. An increase in clotting of blood or a decrease in clotting ability will be considered the two main problems of coagulation of the blood.
Following is a summary of the overall phases of blood clotting. Circulating blood generally has two main inactive proteins relating to clotting. These are prothrombin and fibrinogen. It must also be remembered that platelets stimulate the clotting process.
Blood Clotting Process
PHASE I Initiation Phase
platelets plus initiation factor
PHASE II Thromboplastin Phase
* platelet factors plus Calcium
* plus factors 8, 9, 10, 11, 12
.....yields thromboplastin
PHASE III Thrombin Phase
*prothrombin plus calcium
*plus thromboplastin
*plus accelerator factors 5, 7, 10
..........yields Thrombin
PHASE IV Fibrin Phase
*fibrinogen plus factor 8
*plus Thrombin
.........yields Fibrin CLOT
Test: Platelet Count
A test which is a direct count of platelets (thrombocytes) in whole blood.
Normal Values: 150,000 to 350,000 per mm3 (cubic mm)
Clinical Implications:
  1. Platelets are the smallest formed elements in the blood. They are vital to the formation of the hemostatic plug in vascular injury. They promote coagulation by supplying phospholipids to the intrinsic thromboplastin pathway.
    • Thrombocytopenia - decreased platelet count, below approx 100,000
    • Spontaneous bleeding - if platelets decreased below approx 50,000
    • Fatal GI bleeding or CNS hemorrhage - if platelets below approx 5,000
  2. When the platelet count is abnormal, diagnosis usually requires further studies, such as CBC, bone marrow biopsy, direct antiglobulin test (direct Coomb's test), and serum protein electrophoresis.
  3. Use a 7-ml lavender-top tube for collection. A random specimen is used. Mix the blood GENTLY with the anticoagulant in the tube. Rough handling will interfere with the results.
  4. Hemolysis due to rough handling or to excessive probing at the venipuncture site may alter test results.
  5. Many medications will decrease platelet count; they include acetazolamide, acetohexamide, antimony, antineoplastic drugs, brompheniramine maleate, carbamazepine, chloramphenicol, furosemide, gold salts, isoniazid, mephentoin, methyldopa, sulfonamides, thiazide, and many others.
Platelets normally increase in persons living at high altitudes for extended periods of time. They also increase with persistent cold temperatures, and during strenuous exercise and excitement. The count decreases just prior to menstruation.
Test: Prothrombin Time PT or Pro Time
This test is a measure of phase III of the clotting process. The PT may give false readings due to some other clotting defects. However, it is usually indicative of a phase III problem.
Normal values: (child or adult): 11-15 seconds or 70%-100% (depends on method used)
Clinical Implications:
Prothrombin is also known as factor II of the coagulation factors. It is produced by the liver and requires vitamin K for its synthesis. In liver disease, PT is usually prolonged. The test requires 7 to 10 ml of blood with an anticoagulant in the blood tube. It can be collected in a black-top tube (sodium oxalate in the tube), or blue-top tube (sodium citrate in the tube). The most common is the blue-top tube, the specimen must be tested within 4 hours of collection and is usually packed in ice and delivered to the lab quickly. This is a very common lab test and is usually performed as a routine hospital admission screening test. A high-fat diet may cause decreased PT, and alcohol can cause an increased PT result.
Test: Partial Thromboplastin Time PTT
A test similar to the PT, the PTT is also used to detect clotting abnormalities. APTT, Activated PTT, similar to PTT but is more sensitive than PTT test; it will help to identify the defective factor, if one is defective.
Normal Values:
PTT: 60-70 seconds
APTT: 30-45 seconds
*these results may vary due to test methods in different hospitals.
Clinical Implications:
The PTT is very similar to the PT. It is used to detect Phase II defects in the clotting process. It will usually detect deficiencies in all clotting factors except factors VII and XIII. It is usually performed for monitoring Heparin therapy. Heparin doses are usually adjusted according to the PTT test results. The PTT is usually more sensitive than the PT test.
Test: Bleeding Time
A raw measurement of the time needed for an artificially produced skin puncture to stop bleeding.
Normal Values:
Ivy method: 1-6 minutes
Duke method: 1-3 minutes
Clinical Implications:
Hodgkin's disease is suspected if there is decreased bleeding time. Prolonged rate may indicate: thrombocytopenic purpura, platelet abnormality, vascular abnormality, leukemia, severe liver disease, DIC disease, aplastic anemia, factor deficiencies (V, VII, XI), Christmas disease, hemophilia. The following drugs can affect bleeding time: aspirin, dextran, mithramycin, coumadin, streptokinase-streptodornase (fibrinolytic agent). Aspirin, alcohol, and also anticoagulants may increase bleeding time.
This test is usually inconclusive. It can however, be helpful for diagnosing capillary abnormalities and other disorders. For detecting other clotting problems, this test will usually show a normal result. This test is usually just a general screening test.
Test: TGT, Thromboplastin Generation Time
A test for phase II clotting defects. It tests the ability of the patient to produce thromboplastin.
Clinical Implications:
This test is very complicated and only a few large laboratories will perform this test. The TGT has the ability to exactly pinpoint the defect in the clotting process. This fact can make the TGT a very valuable test under certain circumstances.
Test: Plasma Fibrinogen
A test for the level of circulating plasma fibrinogen.
Clinical Implications:
This test can be very valuable for helping diagnose disorders which can cause lowered levels of the fibrinogen. It is also useful for detecting substances which destroy fibrinogen (fibrinolysins).
Discussion of Coagulation Tests
The tests mentioned here are commonly used in hospitals today. There are many other coagulation tests available, most of which are complicated, expensive, and usually only performed at large medical centers. Many of those specialized tests are used only after simpler screening tests are performed.
The nurse should always remember to obtain a very detailed history from the patient. The history can be most useful in helping the MD make an accurate diagnosis.
Many times the patient may not speak freely with the physician or may have forgotten some important detail or symptom. An observant nurse can possibly help with the medical diagnosis and possibly save the patient extra hospitalization and/or unnecessary testing.
As far as the mechanics of the tests are concerned, there is little for the nurse to do in order to prepare the patients. The nurse should always "warn" the patient that the blood will be drawn, or that they will be injected with something, if it is part of the test. However, most coagulation studies are done with a specimen of blood drawn either randomly or at a special time of the day.
The specimen of blood will probably have an anticoagulant in it or in the collection tube and most specimens will either have to be iced or brought to the lab quickly for analysis.


 http://www.nurseslearning.com/courses/nrp/labtest/course/section3/index.htm

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fotoooo pantaiiii

fotooo 2 gambarr..
 



fotoo dii pantaiii pngenn liat niee.....klik disini


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fotooo

fotoooo preewedddinggg.......


pengen liat nieee klik disini

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blood...poster

posterrr keseehatan


pengen liat  klik disini

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Jantung Koroner

Berbagai jenis penyakit jantung
Kategori jenis penyakit jantung telah diketahui dan penyebab kelainan struktur dan fungsi organ jantung  telah teridentifikasi baik karena kelainan genetik, metabolik, infeksi dlsbya.
Kategori dasar yang sering digunakan :
1.      Penyakit jantung bawaan
2.      Penyakit  jantung  kongestif- gagal jantung  ( Cardiomyopathy)
3.      Penyakit Jantung Koroner ( jantung arteriosklerosis)
4.      Penyakit Jantung Rematik
1. Pengenalan Sakit jantung bawaan
Kebocoran  pada jantung yang disebabkan belum sempurnanya proses penutupan sekat pemisah bilik atau serambi jantung kiri dan kanan, lasimnya terjadi pada masa bayi /anak . Gejala yang sering nampak adalah kebiruan  pada bibir, anak cepat merasa lelah, kadang2 sesak , bahkan mungkin sering pingsan saat beraktifitas.
Penyakit jantung bawaan tersebut meliputi  a.l : ASD : atrial septal defect , adalah kelainan jantung karena ada lobang pada sekat serambi jantung., VSD : venticular septal defect adalah kelainan jantung karena lobang pada sekat bilik jantung, PDA : Patent ductus arteriosus : kelainan tidak menutunya pembuluh darah yang menghubungkan aorta dan arteri pulmonalis dan Tetralogi Fallot, yaitu penyakit jantung bawaan  yang merupakan kombinasi penyempitan pembuluh darah di paru dan adanya lobang pada sekat bilik jantung.
Pemeriksaan penunjang laboratorium seperti elektrolit darah, analisis gas darah dlsbnya serta rangakaian pemeriksaan radiologi  diperlukan dalam diagnosis penyakit jantung  bawaan, agar tindakan koreksi pada kelainan dapat dilakukan secara tepat.
2. Pengenalan  Penyakit jantung kongestif / gagal jantung
Penyakit pada jantung karena ketidakmampuan jantung memberikan suply darah yang cukup untuk kebutuhan seluruh tubuh.Gejala dan keluhan yang menonjol adalah sesak nafas pada posisi tidur terlentang , nafas mudah tersengal bila melakukan gerakan jasmani/olah raga, cepat lelah, batuk dan oedema (pembengkahan sendi pergelangan  kaki) sebagai tanda obstruksi kronis pada pembuluh darah dlsbnya.
Pada umumnya penyakit ini disebabkan infark myocard, penyakit jantung hipertensi dan kelainan katup jantung, serta cardiomyopathi (otot jantung). Namun penyebab lainnya sebagi faktor resiko seperti obesitas, diabetes,  merokok, memberikan konstribusi yang cukup bermakna terhadap kelainan /gagal jantung ini.
Pemeriksaan penunjang baik pada laboratorium maupun radiologik  untuk melakukan identifikasi penyebab perlu dilakukan secara cermat dan efisien. Karena tindakan yang dilakukan harus berpijak pada penyebab dasar ( underlying disease), dan tindakan eksplorasi yang menyeluruh pada penyebab penyakit jantung kongestif akan sangat membantu tatalaksana pengobatan penderita (sperti Diabetes, hipertensi dll).
3. Penyakit Jantung koroner ( penyakit jantung arteriosklerosis)
Penyakit jantung  karena adanya penyempitan pembuluh darah arteri koroner dan berakibat berkurangnya asupan darah dan oksigenasi dinding jantung (miokard). Penempitan ini karena tersumbatnya sebagian pembuluh darah koroner tersebut karena gumpalan darah yang lasim disebut trombosis. Proses tersebut dimulai pecahnya kerak (plaque) arterosklerosis yang memicu bekuan darah yang kompleks.
Gejala dan keluhan yang spesifik adalah rasa nyeri dada seperti menekan atau rasa terbakar didada (angina pectoris) dibagian tengah atau sebelah kiri yang berlangsung 5 sampai 20 menit. Rasa nyeri tersebut menjalar kebahu kiri , terkadang rahang bawah, leher serta punggung .
Pemeriksaan  laboratorium yang sangat diperlukan untuk menunjang diagnosis PJK adalah CKMB ( Creatine Kinase-MB) yang kadarnya akan meningkat pada 5 jam pertama serangan akut tersebut, namun akan menurun setelah 6 jam serangan. Pemeriksaan laboratorium lainya seperti profil lemak, kadar gula, fibrinogen, tes agregasi trombosit  dlsbya sangat membantu  strategi pengobatan yang tepat sasaran
Rangkaian pemeriksaan lainya seperti EKG (elektrokardiografi), tes uji jantung berbeban,  photo thorax, arterografi, scanning dlsbya menentukan tingkat konfirmasi kelainan penyakit jantung koroner tersebut.
4. Penyakit Jantung Rematik
Penyakit jantung jenis ini karena infeksi yang berasal dari infeksi  streptococcus yang berasal dari sakit tonsilopharingitis atau infeksi pada gigi atau gusi. Infeksi itu akan menyebar pada organ jantung melalui aliran darah  dan akan menimbulkan keradangan  pada komponen organ jantung.
Penyakit ini lasimnya menyerang katup jantung  ( katup mitral dan tricuspidal) dan dinding jantung (myocarditis). Kecacatan pada katup mitral dan tricuspidal tersebut akan menyebabkan  stenosis atau insufisiensi dalam memberikan suli darah, sedangkan miocarditis menyebakan kemampuan memompa suply darah kesluruh tubuh tergagnggu.
Pemeriksaan laboratorium yang cermat terhadap kuman penyebab ( ASO titer, C-reactive protein /CRP,darah lengkap) , serta pemeriksaan klinis baik pada tenggorokan maupun pada gigi, EKG dan seangkaian pemeriksaan radiologi akan sangat membantu  pengobatan yang sifatnya medikal maupun tindakan koreksi bedah yang akan dilakukan pada penderita.
Rangkaian pemeriksaan yang umum  untuk konfirmasi adanya serangan jantung
Serangan jantung pada penderita pada tahap pertama  melalui pemeriksaan EKG
(Elektro kardiogram) berupa rekaman /gambaran impuls elektrik jantung. Kemudian disusul pemeriksaan ekhokardiografi dengan ultrasononografi, kedua tes tersebut untuk menilai struktur dan fungsi jantung, kemudian diikuti dengan tes/ rangkaian pemeriksaan darah untuk deteksi kematian sel otot jantung  yang disebabkan karena terhentinya suply / pasokan darah ke jantung, khususnya pada otot jantung (miokardium).
Untuk deteksi otot jantung yang mengalami proses kematian ( sekarat) yang lasimnya mensekresi ensim creatin kinase (CK) , lactic dehydrokinase (LDH) dan protein yang disebut troponin T & I.
Rangkaian pemeriksaan khusus
Adapun untuk konfirmasi yang rinci pada penyakit jantung diperlukan seperti halnya arteriografi atau scanning untuk konfirmasi  lokasi kelainan obstruksi pada pembuluh darah koroner, dan luasnya daerah miokardium yang mengalami infark.

sumber
http://labparahita.com/parahita/2011/02/periksa-dan-pahami-gejala-serangan-jantung/

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Gangguan Faal (Fungsi) Hati

Gangguan Faal (Fungsi) Hati Print
Penderita sering memperlihatkan kepada dokter hasil laboratorium yang mencatat adanya gangguan faal hati, kemudian meminta penjelasan dari hasil laboratorium bahkan memohon pengobatan atas gangguan faal hati tersebut.
Sebagai seorang dokter klinis kita tidak boleh lupa bahwa pertanyaan penderita itu sebenarnya mengacu pada diagnosis penyakit saya itu apa sebenarnya! Untuk bisa menjawab pertanyaan tadi dengan jitu, kita harus mengetahui bagaimana riwayat penyakitnya, simptomatologi serta riwayat yang relevan dengan kondisi klinisnya. Riwayat mengkonsumsi obat-obatan, termasuk obat tradisionil, eksposisi dengan zat kimia/makanan juga perlu diperhatikan. Permeriksaan fisik untuk mencari tanda penyakit hati kronis seperti palmar erithema, jaundice, spider nevi dansebagainya sangat membantu dalam menganalisis hasil laboratorium tadi. Harus diingat bahwa kelainan faal hati, dapat juga dijumpai pada penyakit-penyakit lain diluar penyakit hati, misalnya penyakit kelenjar thyroid, payah jantung dan payah ginjal. Karena itu, kita memerlukan pemeriksaan penunjang lainnya sehingga dapat memberikan kesimpulan dari hasil laboratorium tadi.
Faal Hati yang sesungguhnya.
Hati merupakan organ padat yang terbesar yang letaknya di rongga perut bagian kanan atas. Organ ini mempunyai peran yang penting karena merupakan regulator dari semua metabolisme karbohidrat, protein dan lemak. Tempat sintesa dari berbagai komponen protein, pembekuan darah, kolesterol, ureum dan zat-zat lain yang sangat vital. Selain itu, juga merupakan tempat pembentukan dan penyaluran asam empedu serta pusat pendetoksifikasi racun dan penghancuran (degradasi) hormon-hormon steroid seperti estrogen.
Pada jaringan hati, terdapat sel-sel Kupfer, yang sangat penting dalam eliminasi organisme asing baik bakteri maupun virus. Karena itu untuk memperlihatkan adanya gangguan faal hati, terdapat satu deretan tes yang biasanya dibuat untuk menilai faal hati tersebut. Perlu diingat bahwa semua tes kesehatan mempunyai sensitivitas dan spesifisitas yang berlainan, maka interpretasi dari hasil tes sangat dipengaruhi oleh hal-hal tersebut.
Tes Faal Hati       
Karena faal hati dalam tubuh mempunyai multifungsi maka tes faal hatipun beraneka ragam sesuai dengan apa yang hendak kita nilai.
Untuk fungsi sintesis seperti protein, zat pembekuan darah dan lemak biasanya diperiksa albumin, masa protrombin dan cholesterol. Fungsi ekskresi/transportasi, diperiksa bilirubin, alkali fosfatase. ∂-GT. Kerusakan sel hati atau jaringan  hati, diperiksa SGOT(AST), SGPT(ALT). Adanya pertumbuhan sel hati yang muda (karsinoma sel hati), alfa feto protein. Kontak dengan virus hepatitis B yaitu; HBsAg, AntiHBs, HBeAg, anti HBe, Anti HBc, HBVDNA, dan virus hepatitis C yaitu; anti HCV, HCV RNA, genotype HCV.
Secara umum ada 2 macam gangguan faal hati.
1.      Peradangan umum atau peradangan khusus di hati yang menimbulkan kerusakan jaringan atau sel hati.
2.      Adanya sumbatan saluran empedu.
Aneka macam hasil tes faal hati yang terganggu.
Tes faal hati yang terjadi pada infeksi bakterial maupun virus yang sistemik yang bukan virus hepatitis. Penderita semacam ini, biasanya ditandai dengan demam tinggi, myalgia, nausea, asthenia dan sebagainya. Disini faal hati terlihat akan terjadinya peningkatan SGOT, SGPT serta ∂-GT antara 3-5X nilai normal. Albumin dapat sedikit menurun bila infeksi sudah terjadi lama dan bilirubin dapat meningkat sedikit terutama bila infeksi cukup berat.  (lihat table 1)
Tes faal hati pada hepatitis virus akut maupun drug induce hepatitis. Faal hati seperti Bilirubin direct/indirect dapat meningkat biasanya kurang dari 10 mg%, kecuali pada hepatitis kolestatik, bilirubin dapat lebih dari 10 mg%. SGOT, SGPT meningkat lebih dari 5 sampai 20 kali nilai normal. ∂-GT dan alkalifosfatase meningkat 2 sampai 4 kali nilai normal, kecuali pada hepatitis kolestatik dapat lebih tinggi. Albumin/globulin biasanya masih normal kecuali bila terjadi hepatitis fulminan maka rasio albumin globulin dapat terbalik dan masa protrombin dapat memanjang ( lihat tabel2)
Tes faal hati pada sumbatan saluran empedu. Bilirubin direct/indirect dapat tinggi sekali (>20 mg%), terutama bila sumbatan sudah cukup lama. Peningkatan SGOT dan SGPT biasanya tidak terlalu tinggi, sekitar kurang dari 4 kali nilai normal. ∂-GT dan alkalifosfatase meningkat sekali dapat lebih dari 5 kali nilai normal. Kolesterol juga meningkat  (lihat table 3).
Tes faal hati pada perlemakan hati (fatty liver). Albumin/globulin dan Bilirubin biasanya masih normal. SGOT dan SGPT meningkat sekitar 2 sampai 3 kali nilai normal demikian juga ∂-GT dan alkalifosfatase meningkat sekitar ½ sampai 1 kali dari nilai normal . Kadar triglyserida dan kolesterol juga terlihat meninggi. Kelainan ini sering pada wanita dengan usia muda/pertengahan, gemuk dan biasanya tidak ada keluhan atau mengeluh adanya perasaan tak nyaman pada perut bagian kanan atas. Pada kasus perlemakan hati yang primer maka semua pertanda hepatitis C harus negatif. (lihat tabel 4)
Adanya pertanda hepatitis virus dalam darah penderita.
Penderita hepatitis A akut atau baru sembuh dari hepatitis A, ditandai dengan IgM anti HAV yang positif. Sedang IgG anti HAV positif sering ditemukan pada anak atau orang dewasa dari negara berkembang dengan sanitasi lingkungan yang jelek. Ini menandakan penderita pernah terinfeksi virus hepatitis A dimasa lalu. Karena itu prevalensi IgG HAV dapat dipakai sebagai indeks sanitasi lingkungan suatu negara.
Sembuh dari infeksi Hepatitis B, ditandai dengan menghilangnya HBsAg dan timbulnya anti HBs. Sedang IgM Anti HBc pos, berarti baru (recent) terinfeksi dengan hepatitis B.
Hepatitis B yang menahun.
1.      Hepatitis kronis fase replikatip/toleran. Ditandai dengan HBsAg+, HbeAg+, HBVDNA+ ( kuantitatif dapat >105 copy/ml). Tapi Faal hatinya normal.

2.   Hepatitis kronis reaktif aktif (necro-inflamatory stage). Ditandai dengan HBsAg+, HBeAg+, HBVDNA+ (kuantitatif dapat >105 copy/ml). Tapi Faal hati nya Abnormal, terutama SGOT/PT tinggi (>3X nilai normal), albumin/globulin biasanya masih normal, bilirubin dapat menigkat sedikit (< dari 3 mg%)

3.  Hepatitis khronis B mutant. Disini HBsAg+, HBeAg negatif, tetapi anti HBe+,  dan HBV DNA+. Liver fungsinya terganggu. Biasanya penderita ini, mempunyai penyakit hati yang lebih berat.

4.      Hepatitis inaktif/integratif. HBsAg+, Anti HBe+, HBV DNA negatif atau dibawah < 103 copy/ml dan faal hatinya normal.

5.     Sirosis hati B, rasio albumin/globulin terbalik, Bilirubin meningkat (< dari 5 mg%), SGOT> SGPT, biasanya meningkat sekitar 2 s/d 4 kali normal, tapi pada yang sirosis berat SGOT/SGPT dapat normal. HBsAg+, HBeAg/anti HBe  dapat  positif. HBV-DNA seringnya sudah negatif.
Hepatitis C
1.      Sembuh dari hepatitis C, ditandai dengan anti HCV+, HCV-RNA – (negatif), faal hati yang normal.
2.      Hepatitis C kronik, ditandai dengan Anti HCV+, HCV-RNA +,  faal hati sebagian terbesar terganggu, tapi bisa normal pada sebagian kecil penderita.
3.     Sirosis hati C, rasio albumin/globulin terbalik, Bilirubin meningkat( < dari 5mg%), SGOT > SGPT, biasanya meningkat sekitar 2 s/d 4 kali normal, tapi pada yang sirosis berat SGOT/SGPT dapat normal. Anti HCV dan HCV-RNA positif.
Genotype hepatitis.
Pada hepatitis B ada 8 genotipe dan diberi nama abjad A sampai dengan H. Di Indonesia terutama genotipe B dan C. Hepatitis C ada 6 genotipe dan diberi nama angka 1 sampai 6. Dalam satu genotipe ada dibagi lagi menjadi sub-genotipe dan tambahan huruf kecil dari a sampai c. Di Indonesia yang terbanyak adalah genotipe 1b. (> 65%)
Kelainan faal hati yang tidak specific
Hal ini biasanya terjadi pada penderita penyakit hati yang telah mempengaruhi fungsi dari organ lain seperti ginjal, paru jantung dsb. Dalam hal seperti ini, gambaran klinis serta pemeriksaan penunjang seperti USG, CT scan dan ERCP (Endoscopy Retrograde Cholangio Pancreatography) atau bahkan biopsi hati biasanya diperlukan untuk menegakan diagnosisnya.
Hasil laboratorium faal hati yang normal pada penderita penyakit hati yang menahun.
Penderita kronik hepatitis B pada yang fase replikatif, inaktif/integratif sering menunjukan hasil laboratorium yang normal. Juga pada penderita hepatitis C (dengan HCV-RNA+), juga dapat menunjukan tes faal hati yang normal. Pada penderita sirosis hati yang kompensata juga sering mempunyai tes faal hati yang normal. Pada sirosis hati yang sudah lanjut sering kita mendapatkan kadar SGPT/SGOT normal, hal ini terjadi karena jumlah sel hati pada sirosis berat sudah sangat kurang sehingga kerusakan sel hati relatif sedikit. Tapi kadar bilirubin akan terlihat meninggi dan perbandingan albumin/globulin akan terbalik. Bila kita cermati lebih teliti maka kadar SGOT akan lebih tinggi SGPT.
Pelaporan hasil petanda hepatitis virus secara kuantitatif dan kualitatif.
1.      Hepatitis B.
Pemeriksaan kualitatif selalu lebih sensitif dari pada pemeriksaan kuantitatif. Cara pemeriksaan kuantitiatif hepatitis B dikerjakan dengan bermacam cara dan tiap cara mempunyai sensitivitas tertentu dan juga pelaporannya dapat memakai satuan tertentu. Lihat tabel 5. Hasil kuantitiatif hepatitis B diatas 105 copy/ml dianggap batas untuk diobati.
2.      Hepatitis C.
Juga pemeriksaan kualitatif lebih sensitif dari kuantitatif. Ada bermacam cara pemeriksaan kuantiatif HCV dan mempunyai rentang sensitivitas yang berbeda. Hasil kuantitatif dari 1 cara pemeriksaan kuantitatif HCV,  tidak dapat disamakan hasilnya dengan pemeriksaan HCV dengan cara yang lain. Tabel 6
Penyakit yang jarang tapi menunjukan gangguan  faal hati
  • Penyakit thyroid/kelenjar gondok.
  • Penyakit hati auto immune (AIH)
  • Wilson disease
  • Alpha-1-antitrypsisn deficiency
  • Celiac disease
  • Muscle disorders
  •  
  • sumber http://medicastore.com/penyakit/613/Pemeriksaan_Diagnostik_Untuk_Penyakit_Hati_&_Kandung_Empedu.html

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