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Special investigations
There is little evidence to support the performance of ‘routine’ investigations.
An investigation should only be ordered if the result of it will affect
the way in which the patient will be managed. In patients with no evidence
of concurrent disease, investigations can be limited as in Table 1.1.
ADDITIONAL INVESTIGATIONS The following is a guide to those commonly requested.
- Urea and electrolytes--patients taking digoxin, diuretics, steroids
and those with diabetes, renal disease, vomiting, diarrhea.
- Liver function tests—patients with known hepatic disease, a history
of a high alcohol intake (>50 units/week), with metastatic disease or
evidence of malnutrition.
- Blood sugar—patients with diabetes, severe peripheral arterial
disease or taking long-term steroids.
- Electrocardiogram (ECG)—patients known to be, or found to be, hypertensive
or with symptoms or signs of heart disease.
- Chest X-ray--patients with a history or signs of cardiac or respiratory
disease, suspected or known malignancy, where thoracic surgery is planned
and in those patients from areas of endemic tuberculosis who have not had
a chest X-ray in the last year.
- Pulmonary function tests—patients with dyspnea on mild exertion,
or who are asthmatic, require measurement of peak expiratory flow rate (PEFR),
forced expiratory volume in l second (FEV1) and forced vital capacity (FVC).
Patients who are dyspnea or cyanosed at rest, found to have an FEV1<60%
predicted, or are to have thoracic surgery, in addition to the above should
have arterial blood gas analyzed while breathing air.
- Coagulation screen—patients on anticoagulants, a history of a bleeding
diatheses or a history of liver disease or jaundice.
- Sickle-cell screen (Sickledex)—patients with a family history of
sickle-cell disease or where their ethnic origin puts them at risk of having
sickle-cell disease. If positive, they may need electrophoresis for definitive
diagnosis.
- Cervical spine X-ray—patients with rheumatoid arthritis, a history
of major trauma or surgery to the neck, and those in whom difficult intubation
is predicted.
Fig 1.1 Fig 1.2 Table 1.1
Table 1.1 Baseline Investigation for otherwise Healthy patients.
Medical referral
Optimization of coexisting medical (or surgical) problems may mean postponing
surgery and requesting the involvement of other specialists for advice about
treatment. Physiotherapists as well as physicians play an important role
in improving patients with respiratory problems, either as a result of pulmonary
pathology (e.g. chronic obstructive lung disease) or secondary to neuromuscular
or musculoskeketal disorders. Clearly a wide spectrum of conditions exist,
the following are examples of some of the conditions more commonly encountered.
CARDIOVASCULAR DISEASE
- Untreated or poorly controlled hypertension or heart failure.
- Symptomatic ischemic heart disease, despite treatment (unstable angina).
- Dysrhythmias: uncontrolled atria fibrillation, paroxysmal supraventricular
tachycardia, second and third degree heart block.
- The presence of congenital heart disease or symptomatic valvular heart
disease.
RESPIRATORY DISEASE
- Chronic obstructive airways disease, particularly if dyspneic at rest.
- Bronchiectasis.
- Asthmatics who are unstable, taking oral steroids or have a FEV1 <60%
predicted.
ENDOGRINE DISORDERS
- Insulin and non-insulin dependent diabetics who have ketonuria, glycated
Hb >10% or a random blood sugar >12 mmol/l. Local policy will dictate
referral of diabetics prior to surgery.
- Hypo- or hyperthyroidism symptomatic on current treatment.
- Cushing’s or Addison’s disease.
- Hypopituitarism.
RENAL DISEASE
- Chronic renal failure.
- Patients undergoing chronic dialysis.
HAEMATOLOGICAL DISORDERS
- Bleeding diatheses, for example hemophilia, thrombocytopenia.
- Therapeutic anticoagulation (including aspirin therapy).
- Hemoglobinopathies.
- Polycythemia.
- Hemolytic anemia.
- Leukemia.
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