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1 .541 The Preoperative evaluation and laboratory diagnosis .. 1. 2. 3. 1. 2. 3. 4. 1. Manual of Oral and Maxillofacial Surgery:R Bruce Donoff 2. Clinicians Pocket Reference 8th edition:Nick Pavona 3. A Manual of Laboratory and Diagnosis Test 5th:Frances Fischbach 4. Plain Film Interpretation in Clinical Practice: elective case 1. (Basic life support) Airway,Breathing,Circulation (ABC) cervical spine cervical spine 2. (Obesity) cardiovascular disease aspiration gastric volume pH pharmacokinetics 3. Carbon monoxide (CO) tissue Nicotine (peripheral vasoconstriction) 12-24 CO Nicotine sputum 2 postoperative respiratory morbidity 6-8 4. Myocardial infarction 50% 2 3 infarction ECG ,Echocardiograms Exercise ECG 5. (end-organ disease) , ,autonomic neuropathy,renal insufficiency,cardiomyopathy gastroparesis glucose,electrolyte,BUN,creatinine,urinalysis ECG 6. Alcoholism a. CNS (increased tolerance) withdrawal seizures delirium tremens paradoxical exitation b. alcohol(alcoholic cardiomyopathy) c. gastitis,,hepatitis pancreatitis d. metabolism (increased tolerance) ,sedatives, neuromuscular blocker (increased drug effect) bleeding disorder e. withdrawal tremor,agitation,confusion,increased heart rate spider angiomata,palmar erythema,jaundice,ascites,gynecomastia,enlarged parotids and lacrimals,abnormal coagulation 7. ( Upper respiratory tract infection) (URI) airway reflexes airway secretions bronchospasm,laryngospasm,hypoxia 2 6-7 :What are the appropriate preoperative laboratory tests? Clinical hematology () 1. CBC and Hemogram 2. Blood chemistry test Electrolytes,Renal function test,Liver function test,Cardiac enzyme test,Metabolic bone disease,Glucose,Cholesterol 3. Coagulation bleeding time,PT,PTT,Thrombin time platelet count Urinalysis () Chest X-ray () ECG () 1. Cardiovascular system:CBC,Cardiac enzyme,Coagulation,ECG 2. Respiratory system:Chest X-ray 3. Gastrointestinal system:Liver function test 4. Genitourinary system:Renal function test,Electrolytes,Urinalysis 41. CBC Urinalysis 2. Chest X-ray 3. 40 ECG 4. a. Renal function test BUN,Cr Electrolyte b. Liver function test Albumin,Alkaline phosphatase,Bilirubin,AST,ALT,Total protein Coagulation test c. ECG,Cardiac enzyme test CPK,LDH,AST d. Bleeding disorder Coagulation bleeding time,PT,PTT,Thrombin time platelet count e. Blood glucose 5. 65 CBC,UA,Chest X-ray,ECG,Blood glucose,Electrolyte,BUN,Cr :Laboratory Diagnosis I Clinicial Hematology Blood collection Gauge 22 ethylenediaminetetraacetic acid(EDTA) 3 1. CBC and Hemogram 5 6 CBC white blood cell count ,red blood cell count,hemoglobin ,hematocrit, mean corpuscular hemoglobin (MCH),mean corpuscular hemoglobin concentration,mean corpuscular volume (MCV) platelet count differential WBC count routine CBC CBC Hemogram differential WBC count platelet count platelet (adequate) (inadequate) platelet count CBC :complete blood cell count WBC,RBC,Hgb,Hct Red cell indices Red cell indices MCV,MCH MCHC MCV (mean corpuscular volume)= Hct(%)x 10/RBC(millions/mm3) red blood cell MCH (mean corpuscular hemoglobin)= Hgb(g/100 mL) x 10/ RBC(millions/mm3) Hgb RBC 1 MCHC (mean corpuscular hemoglobin concentration)= Hgb(g/100 mL)/ Hct(%) Hgb Hct Hemogram CBC,differential WBC count platelet count Anisocytosis RBC (variation in RBC size) Hyperchromic hemoglobin hemoglobin (fully saturated)(normochromic) hyperchromic MCH Hypochromic hemoglobin Macrocytic RBC ,diameter>7.7 m;MCV >100 3 Microcytic RBC ,diameter < 6.7 m;MCV < 80 3 Normocytic RBC diameter 6.7-7.7 m,MCV =80 -100 3 Poikilocytosis RBC (Burr cells,sickle cells) Polycythemia RBC 7 Shift to left PMNs (immature polymorphonuclear neutrophils,one or two nuclear lobes) Shift to right four nuclear lobes PMNs The left shift PMN immature PMN(Band or stab cells) immature PMN blood smear nucleus PMN lobe 1-2 lobe PMN lobe nucleus PMN shift to the right left shift Bacterial infection,toxemia,hemorrhage right shift liver disease,megaloblastic anemia,iron deficiency anemia Normal CBC variations Hemoglobin hematocrit (20g/100 ml 60% ) 3 (9.5g/100 ml 32%) WBC (25000/m3) lymphocyte (60%) 5-7 PMN Normal values Hct:Men:47+/-7.0% Women:42+/-5.0% Hgb:Men:14-18 g/100 mL Women:12-16 g/100 mL MCV:85-100 3 MCH:28-31 g MCHC:30%-35% RBC:Diameter:6.7-7.7 m Men:4.2-5.4 x106 cells/mm3 Women:3.6-5.0 x 106 cells/mm3 8 Reticulocytes:0.5%-1.5% WBC:Total:4-11 x103 cells/mm3 Differential WBC count PMN:40%-75% Lymphocytes:15-45% Eosinophils:1%-6% Basophils:0%-2% Monocytes:1%-10% Platelets:145-375 x103 cells/mm3 Differential diagnosis 1. RBC indices 1.1 Decreased MCV,decreased MCH (microcytic,hypochromic) -iron deficiency anemia -thalassemia -anemia of chronic disease 1.2 Increased MCV,increased MCH (macrocytic,hyperchromic) -megaloblastic anemia;B12 folate deficiency -early post-hemorrhage period 2. RBC morphology -Sickled cells- sickle cell anemia -Howell-Jolly bodie- megaloblastic anemia,postsplenectomy -Spherocytes- autoimmune hemolytic anemia,hereditay spherocytosis -Basophilic stippling- lead poisoning -Burr cells- severe liver disease -Helmet cells- uremia,malignant hypertension,hemolytic transfusion reaction -Reticulocytes- hemorrhage,hemolysis,post-Fe2 treatment 3. Hematocrit HCT 30% Hct ,,dehydration,prolonged tourniquet stasis,primary secondary polycythemia 9 (volume overload),anemia(iron deficiency,megaloblastic, sickle cell),,hemolysis 4. White blood cell count (total) acute infections,uremia,steroids,hemorrhage,leukemia radiation,aplastic anemia,infectious mononucleosis,septicemia 5. White blood cell count (differential) Neutrophils (PMNs): infections,granulocytic leukemia,surgery,severe exercise viral infections,aplastic anemia,drugs,radiation,dialysis Shift to left hemorrhage,toxemia,bacterial infection Shift to right iron deficiency anemia,liver disease,megaloblastic anemia Eosinophils: Eosinophil polymorphonuclear granulocyte histamine histamine Eosinophil histamine mast cell eosinophil granule mast cell histamine heparin eosinophil histamine allergic disorders,parasitic infection,collagen vascular diseases,Addisons diaease,malignancy steroids,, ACTH ,Cushings syndrome Basophils: Basophils mast cell (tissue basophil) connective tissue thyroid thymus lipid clearing hypersensitivity heparin,histamine serotonin chronic myeloid leukemia, polycythemia steroids,,acute rheumatic fever,thyrotoxicosis Lymphocytes: viral infections,tuberculosis,mononucleosis,acute and chronic lymphocytic leukemia 10 stress,uremia,steroids Atypical Lymphocytes >20% infectious mononucleosis,cytomegalovirus infection,infectious hepatitis,toxoplasmosis