Endocrine:

 Diabetes
 Fasting state: Glucose- <100mg/dl fatty Acids- 400uM
 Prandial state: Glucose-120-140 mg/dl fatty acids- <400uM
 Plasma glucose: A1c- <7%
 premeal glucose 80-130 mg/dl
 2-hr post-prandial glucose <180 mg/dl
 Hypoglycemia <70 mg/dl
 Oral Glucose Tolerance Test
 2h PG<140 mg/dl = Normal
 2 hr PG 140-190 mg/dl = Prediabetes
 2h PG >200 mg/dl = Diabetes
 A1c
 Normal: 4-5.6%
 Diagnostic Criteria:

Fructosamide
 Normal <285 umol/L
 C-peptide
 Normal fasting: 0.78-1.89 ng/mL
 Urine glucose
 Normal: 180mg/dL
 Thyroid
 TSH
 Normal: 0.5-5.0 milliunits/L
 Free T4
 0.02% unbound
 Total serum T4
 Normal: 5.5-12.5 mcg/dL
 Total Serum T3
 Normal: 80-200 ng/dL
 Thyroid hormone-binding ratio
 Normal: 25-38%

 Radioactive Iodine Uptake

  Normal: 5-25% absorbed in 24h
 Adrenal Gland
 Cortisol
 Normal: >18-20 mcg/dL
 Pft
 Spirometry: best of 3 efforts
 FEV1: >80% predicted
 FEV1/FVC: <70% = obstruction
 TVC is reduced in restrictive and FEV1/FVC is normal
 FEF 25-75% = >70%
 FEV1 focuses on small bronchioles
 SpO2 = >95% / <88% need oxygen
 Drugs of abuse


 Types of Drug tests

 EMIT- widely used / low cost
 RIA- more specific and expensive
 TLC
 GC/MS- most expensive / very specific
 What can be tested
 Breath
 Urine
 Blood
 Heir
 Saliva
 Level of impairment
 Drugs not detected on urine screen
 Androgenic steroids
 GHB
 Anticoagulants
  Meperidine
 Urine collection
 Observation
 Color
 Temperature
 Volume
 Hair analysis – evaluates drug use for 90 days
 Liver


 Albumin
 Normal 4-5 g/dL
 HL- 20 days
 Hypoalbuminemia- <2-2.5 g/dL
 PT/INR
 Normal- PT 12.7-15.4 sec, INR 0.9-1.1 sec
 Alkaline Phosphatase (ALP)
 Normal: 33-96 units/L
 5-nucleotidase/ GGT
 Normal: 5-nucleotidase 0-11 units/L, GGT 9-58 units/L
 GGT/ALP ratio > 2.5 = alcohol abuse


 Bilirubin
 
 Indirect hyperbili- Hemolysis
 Direct hyperbili- Blockage
 Aminotransferases (AST,ALT)
 Normal : AST 12-38 units/L, ALT 7-41 units/L
 AST HL- 17h ALT HL- 47h
 AST/ALT ratio typically > 2:1 And AST rarely > 300 IU/L
 Pancreas
 Pancreatitis caused by gallstones and alcohol abuse
 Lab tests: amylase and lipase
 Amylase
 Normal: 20-96 units/L HL: 1-2h
 Lipase
 Normal: 4-43 units/L HL: 7-14h
 Cardiac da heart



 Cardiac output
 CO=HR x SV
 SV= 70cc
 Afterload= 50cc
 Preload= 120 cc
 70 ml/120ml = ejection fraction
 Cardiac Index
 CO / BSA
 Normal Cl = 2.5 – 4L/min/m2
 2.2 = low cardiac output
 Heart failure assessment
 Ejection fraction
 HFpEF
 HFrEF (<40%) 60% is normal
 BNP/NT-proBNP
 

 Cardiac biomarkers


 Higher troponin levels = higher risk of death and adverse outcomes
 Drugs used for stress testing- Dobutamine and adenosine
 Lipids
 Highest prevalence in southeast
 Pharmacist’s role:
 Screening
 Patient education
  Collaborative Medication management
 Adverse reactions
 Adherence
 Interactions
 Most significant consequiences of dyslipidemia:
 Premature coronary atherosclerosis
 Cholesterol
 Sources:
 Endogenous: 60%
 Exogenous: 40%


 LDL (mg/dL) = total cholesterol – (HDL cholesterol + TG/5)
 Triglycerides (TG)/5 = VLDL cholesterol
 If serum TG>400 mg/dL, LDL must be measured directly


 Triglycerides
 Extreme elevations:
 >500 mg/dL: increased risk of pancreatitis
 >2000 mg/dL: eruptive cutaneous xanthomas
 >4000 mg/dL: lipemia retinalis
 HDL
 1% increase in HDL = 2% (men) and 3% (women) decreases in CVD
 LDL
 1% decrease in LDL = 1% decrease in relative risk for major ASCVD event
 Statins
 Atorvastatin (Lipitor®)strong
 Fluvastatin (Lescol®, Lescol XL®)weakest
  Lovastatin (Mevachor®)weak 2
 Pravastatin (Pravachol®)weak 1
 Pitavastatin (Livalo®)strong
 Rosuvastatin (Crestor®)strongest
 Simvastatin (Zocor®)strong
 Mechanism of action: Inhibit conversion of HMG-CoA to L-mevalonic acid (and
subsequently cholesterol)
 Hyperlipidemia
 Step 1: Determine what statin benefit group they fall into
 Secondary Prevention
 LDL >190mg/dL
 Diabetes
 No diabetes
 Step 2: Calculate 10 year ASCVD Risk score if applicable
 Not needed: Secondary Prevention or LDL >190mg/dL
 Needed for: Diabetes or No Diabetes
 Step 3: Determine appropriate statin intensity
 Moderate or High (Low is not recommended initially)
 Kidney
 GFR:
 Normal renal plasma flow: 625 ml/min
 Normal GFR: 125 ml/min
 Kidneys filter 180L of fluid/ day
 1.5 liters excreted as urine
 >99% of GFR reabsorbed back into blood stream
 Exogenous markers
 Inulin clearance:
 Normal range: men 125 + 15 (SD) mL/min/m2, women 110 + 15 (SD) mL/min/m2
 Iothalamate and Cr-EDTA Clearance
 Normal range: 87 – 141 mL/min/SA
 Cystatin C
 Normal range: men 0.6 – 1.52 mg/L, women 0.57 – 1.45 mg/L
 Serum Creatinine
 Normal range: 0.6 – 1.2 mg/dL
 Urea/ Blood Urea Nitrogen (BUN)
 Normal range: 8 – 23 mg/dL
 BUN and SCr both elevated in acute kidney injury due to dehydration. BUN:SCr ratio > 20:1
 Acute change in renal function AND elevated BUN and SCr
 BUN:SCr ratio > 20:1  prerenal cause
 BUN:SCr ratio between 10:1 – 20:1  intrinsic cause
 Estimating CrCl

CrCl (140 – age) x weight (kg)
x 0.85 (if female)
(mL/min)
= 72 x SCr (mg/dL)
 
 pH and Specific gravity
 Normal range: 4.6 – 8 (average pH around 6)
 SG: Normal range: 1.016 – 1.022
 Urobilinogen and Bilirubin
 Normal range: 0.3 – 1 Erlich Unit (Urobilinogen)
 Normal range: negative
 Hematology


 RBC count- 5,000,000 (5x 106/dL)
 Mean corpuscular volume (MCV)- 80-96 fl/cell ***
 Hematocrit: 40-45%
 MCV <80 – sickle cell, thalassemia
 MVC over 100 = macrocytic / problems with synthesizing DNA cells cannot divide
 B12 deficiency, folic acid deficiency, or drug induced bone marrow toxicity
 MCV normal= normocytic 81-99 fl
 Acute blood loss, hemolytic anemia, anemia of chronic disease
 MCV less than 80 = microcytic
 Iron deficiency, or anemia of chronic disease, iron less than 50, ferritin less than 50
 Reticulocytes: young red blood cells/ response to lack of rbcs / account for 1-2% of total rbcs
 First test done after anemia, if hemolysis if reticulocyte count is over 10%, bone marrow if
less than 1%
 Iron
 Ferritin- 40-200ng/ml
 Less than 15 ng is iron deficiency (ferritin stores iron in the bone marrow)
  Transferrin absorbs iron from the gut and goes up in iron deficiency
 Serum iron (60-150 ug/dL)
 Iron deficiency from pregnancy, bleeding,
 Iron deficiency is microcytic anemia
 Hemolytic anemia
 G6PDH deficiency
 Rbc lysis
 High reticulocyte count over 10%
 Low haptoglobin which bids hemoglobin
 Hemoglobinopathies
 Causes microcytic anemia
 White blood cells
 Total WBC count: 4.4-11.3 x 103 cells/uL
 Neutrophils: 1800-7800/uL (45-73%)
 Bands- 0-700 (3-5%)
 Lymphocytes 1000-4800/uL (20-40%)
 Monocytes- 200-1000/uL (2-8%)
 Eosinophils: 0-450/uL (0-4%)
 Basophils: 0-100/ uL (0-4%)
 Granulocytes
 Neutrophils
 Phagocytic cells to ingest and digest foreign cells and proteins
 90% in bone marrow
 6-8 h in circulation then into tissue
 Increase in bacterial infections, high dose/prolonged corticosteroids, trauma
 Decease in chemotherapy, immunosuppressive therapy
 Absolute neutrophil count= (%neutrophils + % bands) x WBC
 ANC < 1500 cells/uL is neutropenia
 Basophils
 Long-lasting granulocyte: 14 days
 Monocytes
 Mature into macrophages
 Go up in chronic bacterial infection
 Circulate for 16-36 hours
 Lymphocytes
 Deal with intracellular pathogens
 Go down in burns, trauma, HIV, corticosteroids, aplastic anemia
 T cells
 CD4, CD8, Helper T cells
 B cells
 Mature in bone marrow
 Stimulated by t-cells and transformed into plasma cells and produce IgA, IgD, IgE, IgG,
IgM
 
 Hemostasis
 Arterial thrombosis occurs because of an atherosclerotic plaque rupture
 Platelets
 Lifespan: 7-10 days
 Normal range: 150,00-450,000/uL (150-450x103)
 Thrombocytopenia is low platelet
 <50,000 bleeding with trauma
 <20,000 spontaneous bleeding
 Heparin
 Cancer treatment
 Thrombocythemia/ thrombocytosis is high platelet count
 Cancer
 Iron-deficiency
 Recovery from bone marrow suppression
 Platelet activation occurs 2 ways
 1. COX- TXA2 (blocked by aspirin)
 2. ADP- stimulates P2Y12 receptor (blocked by clopidogrel, prasugrel, ticagrelor)
 Used for arterial thrombosis (stents, stroke, or other vascular disease)
 Coagulation test
 Platelets = white clot
 Thrombin = red clot
 
 Extrinsic pathway: damaged tissue (activated tissue factor) 7 bind 10 and 10 binds 5 and
activates 2(thrombin), 2 cuts fibrinogen to fibrin and makes red clot.
 Intrinsic- damaged endothelium (damaged inner layer of vessel activates XIIA) 12 binds to
collagen, binds to 11, binds to 9, binds8, and 10 is activated
 aPPT for intrinsic and common
 PT is extrinsic
 Heparin blocks 10a activation / so do LMWH and 10a inhibitors / also blocks 2a (bivaluridine
snake venom DTI)direct thrombin inhibitor
 PT/INR
 PT is 12 seconds
 INR is 1 second
 PT- 2,5,9,10 (vitamin K dependent) measured effect
 INR therapeutic range- 2-3 or 2.5-3.5 for mechanical valve
 aPPT
 Normal range: 22-38 seconds
 Monitors heparin and direct thrombin inhibitors
 Activated Clotting time
 Normal range: 70-180 sec
 Monitors high dose heparin and DTIs
 Anti-Xa
 Therapeutic range:
 Heparin: 0.3-0.7 units/mL
 LMWH: 0.5-1.0 units/kg
 1- 2 units/kg daily dosing
 LMWH used for pregnancy, obesity, and impaired renal function
 Thrombophilia
 Hypercoagulable state (likes to clot)
 Antithrombin III deficiency / Protein C&S / Factor V Leiden / antiphospholipid antibodies (in
Lupus) – all oppose clotting cascade (deficiency means that there is nothing there to stop
the clotting)
 D-dimer
 Clot turn over measurement (tests clot formation and degradation)
  Normal range is <200ng/ml
 Over 500 has clots or DVTs
 Electrolytes
 Fluids
 Account for 60% for total body weight
 2/3 intracellular fluids
 1/3 extracellular fluids
 80% interstitial fluid /25% tbw
 20% plasma / 8% tbw
 Electrolytes
 Intracellular
 Potassium, magnesium, phosphorus
 Extracellular
 Sodium, chloride, bicarbonate
 Sodium
 Normal range: 135-145 mEq/L
 Primary extracellular cation
 Hypernatremia- more than 145
 High, normal, or low sodium content
 Hyper with brain
 Caused by impaired thirst mechanism, renal or gi losses
 Acute elevation > 160 mEq/L associated with 75% mortality rate

 Hyponatremia less than 135
 Slow with brain
 When Can occur when total body water and sodium is low (hypovolemic), normal
(euvolemic/ drinking too much water), or high (hypervolemic/ most frequent/ in
conditions such as heart failure or liver failure)
 2 main causes
 Asymptomatic until serum sodium is <120 mEq/L
 Assessing fluid status
 Fractional excretion of sodium (FENa)
 Normal range: 1-2%
 Measures % of filtered sodium excreted in the urine
 > 2% = kidneys excreting higher than normal fraction of Na  renal tubular damage
 < 1% = prerenal causes of renal dysfunction (e.g. dehydration, cardiac failure)
 Blood urea nitrogen (BUN): Serum creatinine (SCr) ratio
 Normal range: < 20:1
 If ratio is higher than 20:1, usually indicates dehydration
 Potassium
 Normal range: 3.8-5 mEq/L
 Primary intracellular cation
 Hypokalemia
 Acidosis is hypokalemia
  Alkalosis is hyperkalemia
 Vomiting, diuretics, hyperaldosteronism, Cushing’s syndrome -main causes for
hypokalemia
 Causes ST depression and prolonged QT
 Prominent U wave
 Leads to cardiac arrest
 Loss of smooth muscle function: weakness, cramps
 Hyperkalemia
 Serum potassium >5 mEq/L
 Caused by metabolic acidosis
 Renal failure is the most common cause