Clinical Problems and Suggested Tests

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The following checklist is submitted only as a guide to clinical practice, following requests for advice on appropriate pathology tests from many doctors over the years. This list is neither exhaustive nor authoritative, and should only be regarded as a prompt to assist the busy practitioner.

Clinicians must make individual decisions in consultation with their patients based on individual clinical circumstances. Obviously, in individual and specific circumstances, some tests mentioned will be irrelevant; equally, other tests not on the list may be very appropriate. The tests are organised into first-stage, second-stage and more specialised tests, to encourage appropriate ordering strategies.

You may also refer to the Complete Clinical Problem Listing from The Royal College of Pathologists of Australasia manual or Lab Tests Online for guidance in clinical scenarios.

Troponin T - Additional testing information

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Alopecia
- First stage test	TFT, iron studies, antinuclear factor, ESR
- Second stage test	Testosterone, SHBG, Fungal microscopy and culture
- More specialised tests	Skin biopsy

Amenorrhoea
- First stage test	Quantitative HCG, follicle stimulating hormone, luteinsing hormone, oestradiol, TFT,
- Second stage test	Prolactin, testosterone SHBG

Ante-natal screen (before 20 weeks)
- First stage test	FBE, blood group & antibodies, Rubella, Syphilis, HIV, Hepatitis B & C serology, urine mcs, cervical cytology
- More specialised tests	First trimester and second trimester Downs screening tests

Ante-natal screen (for 26 - 28 Weeks)
- First stage test	Blood group & antibodies, glucose tolerance test

Ante-natal screen (for 30 - 36 Weeks)
- First stage test	FBE, group B Streptococcus screen

Anti-coagulant therapy (initial monitoring of warfarin therapy)
- First stage test	INR

Arthritis
- First stage test	Serum uric acid, rheumatoid factor, antinuclear factor, extractable nuclear antigen, ESR, C-reactive protein
- Second stage test	HLA B27, complement, faeces mcs, Ross River virus serology, Barmah Forest virus serology, Parvovirus B19 serology, Hepatitis B serology
- More specialised tests	Iron studies

Atypical pneumonia / chronic cough
- First stage test	Sputum mcs, Mycobacterium tuberculosis culture, Legionella serology and culture, serology for Mycoplasma & Chlamydophila pneumoniae.
- Second stage test	PCR/Serology for Bordetella pertussis, PCR/serology for influenza A & B & parainfluenza & respiratory syncytial virus, adenovirus PCR, Q Fever serology
- More specialised tests	Mantoux

Bleeding tendency
- First stage test	FBE, INR, APTT, fibrinogen, LFT
- Second stage test	Platelet function analysis, coagulation factor studies, platelet aggregation

Chest pain
- First stage test	Troponin, creatine kinase
- Second stage test	Repeat first stage tests, D dimer

Dementia
- First stage test	FBE, ESR, U&E, TFT, TFT calcium, Vitamin B12
- Second stage test	Red cell folate, Syphilis serology, blood lead

Depression
- First stage test	FBE, fasting blood glucose, TFT, calcium, Vitamin B12
- Second stage test	24 hour urinary cortisol, urine drug screen

Diabetes monitoring
- First stage test	HBA1c, urine albumin, lipids, U&E
- Second stage test	Vitamin B12, TFTs

Diarrhoea
- First stage test	Faeces mcs x2 (Due to HIC requirements only one culture and two microscopies can be performed in 7 days)
- Second stage test	Reducing substances, Clostridium difficile toxin, rotavirus, adenovirus
- More specialised tests	Vasoactive intestinal polypeptide, platelet serotonin, coeliac serology, bowel biopsy

Erectile dysfunction
- First stage test	Testosterone, SHBG, luteinsing hormone, LFT, fasting glucose, lipids
- Second stage test	Iron studies,

Fatigue / weakness
- First stage test	FBE, TFT, U&E, LFT, fasting glucose
- Second stage test	Serum calcium, iron studies, EBV serology, Ross River virus serology, Barmah Forest virus serology, CMV serology, Parvovirus B19 serology
- More specialised tests	Creatine kinase, antinuclear factor, acetylcholine receptor antibody, 8-9am cortisol

Gynaecomastia
- First stage test	LFT, U&E, TFT, Oestradiol, Testosterone SHBG
- Second stage test	Luteinsing hormone, follicle stimulating hormone, prolactin
- More specialised tests	Urine drug screen (especially THC), fine needle aspiration

Hepatomegaly +/- Liver Dysfunction
- First stage test	FBE, LFT, Hepatitis A, B & C screen
- Second stage test	Iron studies, CMV serology, EBV serology, fasting glucose
- More specialised tests	Fasting blood glucose, lipids, antinuclear factor, serum alpha-foetoprotein, carcinoembryonic antigen, Hydatid serology, Q Fever serology

Hirsutism
- First stage test	Testosterone, free testosterone, follicle stimulating hormone, luteinsing hormone, DHEAS androstenedione
- Second stage test	24 hour urinary cortisol, 17 hydroxy progesterone

Hyperlipidaemia
- First stage test	Lipids, HDL cholesterol, fasting blood glucose
- Second stage test	LFT, TFT, U&E

Hypertension
- First stage test	Urine mcs, fasting blood glucose, U&E
- Second stage test	TFT, urine catecholamines, urine cortisol, renin, aldosterone

Infertility – female
- First stage test	Oestradiol, progesterone, follicle stimulating hormone, luteinsing hormone
- Second stage test	Prolactin, TFT, 8 - 9am cortisol
- More specialised tests	Testosterone, free testosterone, 17 hydroxy progesterone, chromosome studies (blood)

Infertility – male
- First stage test	Semen analysis
- Second stage test	Testosterone, follicle stimulating hormone, luteinsing hormone, fasting blood glucose, prolactin, TFTs
- More specialised tests	Chromosome studies (blood), iron studies, sperm antibodies, testicular biopsy

Inflammation
- First stage test	FBE, ESR, C-reactive protein
- Second stage test	Urine mcs, U&E, LFT

Lymphadenopathy
- First stage test	FBE, ESR, EBV serology, CMV serology, Toxoplasma serology
- Second stage test	Angiotensin converting enzyme, Syphilis serology, HIV serology, TFTs
- More specialised tests	Fine needle aspiration +/- flow cytometry, culture including atypical mycobacteria, PCR for Bartonella henselae

Malabsorption, failure to thrive
- First stage test	FBE, urine mcs, reducing substances, faeces mcs (including fat globules)
- Second stage test	Vitamin B12, folate, LFT, HIV serology, iron studies
- More specialised tests	Immunoglobulin A & G & M, serum carotene, GAD antibodies, endomysial antibody, small bowel biopsy

Obesity
- First stage test	Fasting blood glucose, TFT, 24 hour urinary cortisol
- Second stage test	Lipids
- More specialised tests	Dexamethasone suppression test

Peripheral neuropathy
- First stage test	Vitamin B12, fasting blood glucose, U&E
- Second stage test	LFT, porphyrin screen (urine or faeces), ) Vitamin B6, Serum protein electrophoresis, urine Bence Jones protein
- More specialised tests	Heavy metals (lead, arsenic, thallium)

Pharyngitis
- First stage test	Throat swab for MC&S, resp virus PCR, FBE, monospot
- Second stage test	EBV serology

Polyuria
- First stage test	Fasting blood glucose, U&E, urine mcs, serum calcium
- Second stage test	Osmolality (serum and urine, collect early morning urine)
- More specialised tests	Water deprivation test

Pyrexia of Unknown Origin
- First stage test	Blood cultures, FBE, ESR, C-reactive protein, LFT, urine mcs, Malarial parasites & Dengue Fever serology (if relevant travel)
- Second stage test	Angiotensin converting enzyme, faeces mcs
- More specialised tests	CMV serology, EBV serology, Brucella serology, Q Fever serology, Toxoplasma serology, Syphilis serology, HIV serology, Leprospirosis serology, Beta 2 microglobulin, Rickettsial serology

Recurrent / persistent infections (immune deficiency)
- First stage test	FBE, ESR, immunoglobulin A & G & M, protein EPG, HIV serology, fasting glucose
- Second stage test	Complement, lymphocyte surface markers (blood)

Recurrent miscarriage
- First stage test	Testosterone, SHBG, TFT, antinuclear factor, anti-cardiolipin antibodies
- Second stage test	Fasting blood glucose, Chlamydia PCR, lupus anti-coagulant
- More specialised tests	Chromosome studies (blood), culture for Listeria

Renal impairment / failure
- First stage test	Urine mcs, urine albumin, U&E, LFT, fasting blood glucose, prostatic specific antigen, serum uric acid
- Second stage test	Creatinine clearance, urine protein
- More specialised tests	Antinuclear factor

Splenomegaly
- First stage test	FBE, ESR, LFT, rhematoid factor
- Second stage test	Hepatitis B & C serology, INR, APTT, fibrinogen, angiotensin converting enzyme, antinuclear factor, EBV serology, CMV serology, HIV serology
- More specialised tests	Malarial parasites, Mantoux test, flow cytometry (blood), osmotic fragility

Suspected illicit drug usage
- First stage test	Urine drug screen, LFT
- Second stage test	Hepatitis B & C serology, HIV serology

Thrombotic tendency / investigation of DVT
- First stage test	FBE, INR, APTT, fibrinogen, lupus anti-coagulant, anti-cardiolipin antibodies, prothrombin gene mutation, protein C and S, anti-thrombin III

Tumour markers
- First stage test	Carcinoembryonic antigen, CA 125, CA 19-9
- Second stage test	Serum alpha-foetoprotein, HCG (tumour marker), CA 15.3
- More specialised tests	BRCA2 (breast cancer gene)

Urethritis
- First stage test	First void urine, PCR for Chamydia and Gonorrhoeae; MSU for MC&S
- Second stage test	Syphilis serology, HIV serology

Weight Loss
- First stage test	FBE, TFT, U&E, fasting glucose
- Second stage test	LFT, CRP, 8-9am cortisol
- More specialised tests	Short synacthen stimulation test, carcinoembryonic antigen, CA 125, CA 19-9