1993 • Aspen Publishers, Inc.
Thanks to the National Guideline Clearinghouse™ (NGC), a public resource for evidence-based clinical practice guidelines, for the use of this document!
MAJOR RECOMMENDATIONS:
Jump to:
I. History and Physical Examination
II. Diagnostic Imaging
III. Instrumentation
IV. Clinical Laboratory
V. Record Keeping and Patient Consents
VI. Clinical Impression
VII. Modes of Care
VIII. Frequency and Duration of Care
IX. Reassessment
X. Outcome Assessment
XI. Collaborative Care
XII. Contraindications and Complications
XIII. Preventive Maintenance Care and Public Health
XIV. Professional Development
DEFINITIONS
Note from NGC: The recommendations, presented below, were the most important part
of the proceedings. At all times, however, it must be kept in mind that the
recommendations should not be perceived as free floating statements. Each recommendation
must be placed in the context of the entire document. The scientific and theoretical base
of a recommendation must be kept in mind, as well as its relationship to other
recommendations. The definitions of the ratings for the documents - the practice rating
(e.g., "necessary"), the quality of evidence in support, and the consensus level
- are provided in the "Rating Scheme" field of the NGC full summary and are
repeated at the end of this major recommendations section. The following excerpt of the
major recommendations of the guideline is provided for reference purposes only:
History and Physical Examination:
History
The process by which one determines the diagnosis should be adequately recorded and
interpretable.
| Rating: |
Necessary |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
The history plays a critical role in the diagnostic process. A well-performed history will appropriately identify the region to be examined and the extent of the condition.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
The components of the history may include any or all of the following, dependent on the
presentation of the patient and the judgment of the practitioner.
Data on identity, including age and sex
Chief complaint (problem list)
History of present complaint
Family history
Past health history
general state of health
prior illness
surgical history
previous injuries, i.e., MVA, workers’ comp.
past hospitalizations
previous treatment and diagnostic tests
medications
allergies
Psycho-social history
occupation
activities
recreational activities
exercise
Social history
marital status
level of education
social habits
Review of systems
musculoskeletal
cardiovascular
respiratory
gastrointestinal
genitourinal
central nervous system
eye, ear, nose and throat
endocrine
peripheral vascular disease
psychiatric
| Rating: |
Necessary |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Examination
Practitioners may use any or all diagnostic procedures pertinent to the physical
examination, however sophisticated, dependent on individual training and the legal
statutory framework within which they work.
| Rating: |
Necessary |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Examination procedures regardless of chief complaint(s) may include:
Evaluation of blood pressure and pulse rate
Recording of height and weight
Record of temperature in the presence of pertinent subjective complaints
| Rating: |
Recommended |
| Evidence: |
Class III |
| Consensus Level: |
1 |
In the presence of head complaints evaluation may include examination of the neck and
adjacent structures as well as appropriate vascular and cranial nerve testing.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
In the presence of reported or observed changes in cognition, coordination, special
sensory function or recent head trauma, it is necessary to perform a neurologic evaluation
or obtain a more extensive neurologic/vascular workup in a timely fashion.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Examination of the neck and adjacent structures may include:
Inspection and observation to include postural presentation of the region
Regional palpation
Range of motion including active and/or passive movement
Muscle strength
Provocative maneuvers which might include compression and stretching
Neurologic examination
Vascular examination
as is safe and effective in diagnosing the patient.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Examination procedures for thoracic and/or chest complaints may include:
Inspection and observation to include postural presentation of the region
Regional palpation
Auscultation of the chest in the presence of pertinent subjective complaints to be
performed by the practitioner or appropriate specialist
Auscultation of heart sounds in the presence of pertinent subjective complaints to be
performed by the practitioner or appropriate specialist
Auscultation and palpation of the abdomen
Range of motion including passive and/or active movements
Muscle strength
Provocative maneuvers which may include compression and stretching
Neurologic examination
as is safe and effective in diagnosing the patient.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Examination procedures for lower back and adjacent structures may include:
Inspection and observation to include postural presentation of the region
Regional palpation
Evaluation of the abdominal aorta to include palpation and auscultation in the presence
of pertinent subjective and objective findings
Evaluation of the abdominal/pelvic viscera to include palpation and/or auscultation in
the presence of pertinent subjective complaints
Range of motion including passive and/or active movements
Muscle strength
Provocative maneuvers which may include compression and stretching
Neurologic examination
]Vascular examination
Recording the circumference of the involved extremity in the presence of pertinent
subjective complaints
as is safe and effective in diagnosing the patient.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Examination procedures for extremity complaints may include:
Vascular examination
Neurologic examination
Regional palpation
Range of motion including passive and/or active movements
Provocative maneuvers which may include compression and stretching.
Recording the circumference measurements of the involved extremity in the presence of
pertinent subjective complaints.
as is safe and effective in diagnosing the patient.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Independent chiropractic examinations (ICE) should be performed in accordance with the
recommendations put forth in this chapter.
| Rating: |
Recommended |
| Evidence: |
Class II |
| Consensus Level: |
1 |
Diagnostic Imaging:
Sequence of Services
The practitioner, in most instances, is the person that
initiates a radiographic study. The study is performed by the technologist or qualified
person in a safe environment in a manner consistent with published guidelines regarding
quality and performance. It is the standard of care that all studies are viewed for
interpretation by the practitioner or radiologist to obtain the maximum level of diagnosis
which is achievable based on the type of study performed. Standard and customary billing
procedures are followed.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Patient Selection Procedures
The decision on whether or not to use diagnostic
imaging studies is made following a carefully performed history, physical and regional
evaluation, and consideration of cost/ benefit/radiation exposure ratios. It is based on
sound clinical reasoning and the likelihood that significant information can be obtained
from the study in regards to diagnosis, prognosis and therapy. The decision remains solely
the domain of the examining (primary) practitioner.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Comment: It is difficult to weigh the impact of the political, litigious, and
social climate on the perceived need of many practitioners to have prior radiographic
evidence of the area to be manipulated. This issue needs further study before firm
conclusions about the prophylactic acquisition of radiographs can be made.
Radiographic Interpretation and Reporting
Imaging studies are performed primarily
to contribute to a diagnostic impression. Interpretation of each imaging study should be
documented in the patient’s permanent record.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Legal Issues in Radiography
Federal regulations (Public Law 97-35 sec. 978) state
that radiography, as applied to chiropractic practice, is used for diagnostic purposes
only, and not for radio-therapeutic purposes. The National Council on Radiation Protection
has established recommendations for the safe and effective use of radiography. It is the
responsibility of every practitioner to be informed of and abide by all relevant legal
requirements.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Radiation Technology and Protection
Practitioners should keep the radiation
exposure of patients as low as reasonably achievable. This includes use of modem equipment
and techniques as outlined in the literature review section of this document. A suboptimal
radiograph should be repeated. The decision on whether or not to expose a patient to
radiation is only valid before the series is ordered. Once committed to the acquisition of
a series, the practitioner is obligated to produce high quality radiographs.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Plain Film Radiographs
The plain film radiograph is considered an adequate first
step in the evaluation of degenerative and inflammatory joint disease, fracture, infection
and neoplasm. Not every patient with these conditions will require radiography for
diagnosis. Orthogonal views are a necessary minimum for visualizing any body area.
Additional views are used as appropriate to demonstrate conditions that could exist given
the findings of the clinical diagnosis.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
For postural and biomechanical assessment.
| Rating: |
Promising |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Full Spine Radiography
For scoliosis evaluation where indicated by clinical
examination.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
For evaluation of complex biomechanical or postural disorders and the evaluation of
multi-level spinal complaints as a result of biomechanical compensation.
| Rating: |
Promising |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Stress Radiography
Stress views are often of value in the assessment of degenerative, traumatic or
post-surgical instabilities with the exception of those that carry the risk of neurologic
injury. They provide unique diagnostic information.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
For other conditions and circumstances.
| Rating: |
Equivocal |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Videofluoroscopy (cinefluoroscopy)
For kinematic and other biomechanical
purposes.
| Rating: |
Promising |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Comment: The authors of the Quebec Task Force (1987) have outlined the limited
use criteria that currently appear valid.
For instability of the wrist and contrast studies.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Plain Film Contrast Studies
Provide valuable unique information in special
circumstances. These studies should only be performed by a radiologist.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Computed Tomography
Valuable in the assessment of most musculoskeletal conditions requiring sectional
imaging. Of particular utility in the evaluation of complex fractures in flat bones or the
posterior arch of any spinal level. Adequately sensitive and specific for the evaluation
of complicated degenerative conditions and herniated nucleus pulposus of the lumbar spine.
Ordered only in the presence of specific clinical indications.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Magnetic Resonance Imaging
The study of choice in the pre-operative evaluation of
many internal derangements of articulations, and the evaluation of many central nervous
system disorders. Comparisons between CT and MRI have shown similar sensitivity. Limited
spatial resolution capabilities and cost are drawbacks. Ordered only in the presence of
specific clinical indications.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Radionuclide Bone Scanning
Has an established role in the evaluation of bone
disease. Adequately sensitive, put poorly specific. Ordered only in the presence of
specific historical and diagnostic information.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Diagnostic Ultrasound
Utility and accuracy in the evaluation of musculoskeletal
conditions remains limited, but diagnostic ultrasound has promise as a non-invasive,
inexpensive alternative to MRI and arthrography. An established modality for evaluation of
many intra-abdominal and pelvic organs.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Instrumentation:
Perceptual Measurements
Questionnaires as Instruments
Questionnaire instruments are safe and effective.
Several instruments have been fully validated, are widely used and well established. Their
use is supported by both Class I (modified to the discipline of measurement) and Class II
evidence.
Strength of recommendation: Type A.
Consensus Level: 1
Screening Questionnaire
Their use is safe and effective, supported by Class II
and Ill evidence.
Strength of recommendation: Type C.
Consensus Level: 1
Pressure Algometry
Pressure algometry is safe and effective when contrasted with
normative values for region and gender. It is a new procedure that is not yet in wide use
but is promising. Its use is supported by Class II and Class III evidence.
Strength of recommendation: Type B.
Consensus Level: 1
Functional Measurements
Measurement of Position/Clinical Anthropometry (Posture)
Plumbline Analysis
Plumbline analysis is safe and effective when used to assess
upright posture. It can be administered by persons with minimal training but should be
interpreted by a professional health-care provider. The procedure is widely used,
established and supported by both Class II and Class III evidence.
Strength of recommendation: Type B.
Consensus Level:1
Scoliometry
Scoliometry is safe and effective and can be administered by persons
with minimal training but should be interpreted by a professional health care provider.
The procedure is well established and supported by both Class I and Class II evidence.
Strength of recommendation: Type A.
Consensus Level: 1
Photogrammetry Methods
Photogrammetry methods are safe and effective means to
quantify topographical or structural anomaly and work postures. Training is necessary to
avoid error sources and assure reliability of measures. The procedures are well
established and supported by evidence in Classes I, II and III.
Strength of recommendation: Type A.
Consensus Level: 1
Moire Topography
Moire topography is safe and can be administered by persons with
minimal training but requires oversight on technical procedures. It is of limited
effectiveness. The procedure is promising only as a qualitative screening method supported
by Class II and Class III evidence.
Strength of recommendation: Type B.
Consensus Level: 1
Bilateral Weight Distribution
Bilateral weight scales are safe but their
effectiveness is unknown and is rated as equivocal. Class II and III evidence is
available.
Strength of recommendation: Type C.
Consensus Level: 1
Automated Measurements of Posture
Automated methods have received limited
acceptance and are rated as promising. They are safe to administer but their effectiveness
is limited by the training and practice of the operator. Fundamental difficulty in
landmark identification and limited information on reliability restricts the use to
screening purposes. Their use is supported by Class II and Class III evidence.
Strength of recommendation: Type B.
Consensus Level: 1
Measurement of Movement
Goniometers
Goniometers are widely used, safe and effective. They are established
to measure peripheral joint motion although the margin of error remains high. Class I and
Class II evidence supports their use.
Strength of recommendation: Type A.
Consensus Level: 1
Inclinometers
Inclinometers are established for measurements of spinal motion.
Their common use is supported by Class I and Class II evidence and is safe and effective.
Strength of recommendation: Type A.
Consensus Level: 1
Optically Based Systems
Optically based systems are established for evaluating
specific gait abnormalities or risky positions related to work tasks. They are safe and
effective when evaluated by specially trained personnel and are supported by Class II
evidence.
Strength of recommendation: Type B.
Consensus Level: 1
Computer Assisted Range of Motion Systems
Computer assisted range of motion
systems provide improved levels of precision and reproducibility. They are safe, effective
and non-invasive. They require specialized training and should be interpreted by a
qualified health care provider. Clinical applications are promising. Class II and III
evidence is available.
Strength of recommendation: Type B.
Consensus Level: 1
Measurement of Strength
Manual Strength Testing
Manual strength testing is widely used, safe and largely ineffective for strength
differences less than 35%. Hand held load cells may assist in finding smaller differences
in extremity muscle strengths. It is established as a screening procedure and is supported
by Class I and Class II data.
Strength of recommendation: Type A.
Consensus Level: 1
Isometric Strength Testing
Isometric strength testing is an established procedure
that is effective for limited applications involving employment evaluation and post-injury
assessment where relevant standards can be determined. The methods are safe when performed
by trained personnel who can make appropriate clinical judgments with respect to patient
limitations during the procedure and when contraindications are observed. Class I and
Class II data are available.
Strength of recommendation: Type A.
Consensus Level: 1
Isokinetic Strength Testing
Isokinetic strength testing is widely used, safe for
non-acute disorders and effective for making bilateral comparisons or contrasting
performance to normative data. The procedures are well established in sports applications
and promising for post-injury use after the acute phase of treatment has passed. Class II
and Class III evidence supports its use.
Strength of recommendation: Type B.
Consensus Level: 1
Isoinertial Strength Testing
Isoinertial strength testing is a promising
procedure for employment selection and post-injury applications. It is safe for non-acute
disorders when carried out by trained personnel. Class II and Class III evidence has been
reported.
Strength of recommendation: Type C.
Consensus Level: 1
Physiologic Measurements
Thermographic Recordings
Thermocouple Devices
Thermocouple devices are still in use. While they are safe,
there is no evidence to support a claim of effectiveness. Their use is rated doubtful and
is supported by Class II and Class III evidence.
Strength of recommendation: Type D.
Consensus Level: 3
Infrared Thermography
Infrared thermography is a safe procedure of intense
controversial effectiveness. Its use requires specially trained personnel and specially
adapted surroundings. Its rating as equivocal/promising is supported by continuing
controversy from Class II and Class III evidence.
Strength of recommendation: Type C because of the controversy.
Consensus Level: 3
Galvanic Skin Response
These types of measurement are safe, but generally
ineffective as a result of questions remaining on reliability and validity from Class II
and Class III types of evidence. For general arousal studies they are considered
investigational.
Strength of recommendation: Type D.
Consensus Level: 1
For acupuncture point finding and for assessing spine-related disorders, they are
considered as doubtful.
Strength of recommendation: Type E.
Consensus Level: 1
Electrophysiologic Recordings
All of the electrodiagnostic methods are safe when
carried out by specially trained personnel. Interpretation should be carried out only by
physicians with extensive training in the technical and clinical considerations that can
readily confound the findings.
Kinesiologic Surface (Scanning) EMG
Kinesiologic surface (scanning) EMG is a
rapidly proliferating, safe procedure that has not been shown effective with the exception
of limited use for flexion/relaxation and mean/ median frequency shifting measures.
Generally, its use remains investigational. Specific procedures of flexion/relaxation and
mean/median frequency shift evaluation are considered promising based on Class II and
Class III evidence.
Strength of recommendation - scanning surface
EMG: Type C.
Consensus Level: 2
Strength of recommendation - flexion/relaxation and mean/median frequency shift
measures: Type B.
Consensus Level: 1
Surface Electrodiagnostic Procedures (NCV, F-wave, H-Reflex, SSEP)
Surface
electrodiagnostic procedures (NCV, F-wave, H-reflex, SSEP) are established procedures
effective for examination of peripheral nerve disorders and are supported by Class I and
Class II evidence. Somatosensory evoked potentials are established for limited
applications to peripheral nerve disorders and lesions affecting the long sensory tracks
of the spinal cord.
Strength of recommendation: Type A.
Consensus Level: 1
Needle Electrodiagnostic Procedures (EMG, NCV, F-wave, H-reflex, SSEP)
Needle
electrodiagnostic procedures (EMG, NCV, F-wave, H-reflex, SSEP) are widely used,
established procedures that are affective in assessing functional effects of pathology
affecting the central and peripheral nervous system and muscle. Class I and Class II
evidence is available.
Strength of recommendation: Type A.
Consensus Level: 1
Electrocardiography
ECG is a widely used, safe, effective and established
procedure for aiding in the differential diagnosis of complaints that may be
cardiopulmonary in origin. Interpretation requires specialized training. Class I and Class
II evidence is available.
Strength of recommendation: Type A.
Consensus Level: 1
Procedures
Clinical laboratory testing is an established
approach that is widely used, safe and effective when used in differential diagnosis. Test
procedures require appropriate technical instrumentation operated by specially trained and
certified staff as determined by law. Equipment must be kept calibrated and standardized.
Quality assurance procedures must be followed to ensure accuracy and reliability. Class I,
II and III evidence is available.
Strength of recommendation: Type A.
Consensus Level: I
Other Instrument Measures
Doppler Ultrasound
Doppler measures are well established, safe and effective as
means to quantify the presence of vascular disease. Special training is necessary and a
trained health care provider should interpret results. Both Class II and Class III data
are available.
Strength of recommendation: Type B.
Consensus Level: 1
Plethysmography
Plethysmography is used on occasion. It is safe and effective
when tissue volume changes and a symptom or peripheral vascular differential diagnosis is
needed. Use for these purposes is well established. Special training is necessary and a
trained health care provider should interpret results. Its effectiveness as a monitor of
treatment of spine disorders is not determined and use for this purpose should be
considered investigational. Class II and Class III data are available.
Strength of recommendation - differential diagnosis: Type B.
Consensus Level: 1
Strength of recommendation - monitor spine disorders: Type D.
Consensus Level: 1
Spirometry
Pulmonary function testing is established as a method to assess effect
of severe scoliosis and the differential diagnosis of lung disease. These uses are backed
by Class I and Class II evidence. The procedures are safe and effective when performed by
appropriately trained personnel.
Strength of recommendation: Type A.
Consensus Level: 1
Clinical Laboratory:
General
The Role of Laboratory Procedures in Chiropractic Practice
The appropriate use of
clinical laboratory procedures in chiropractic practice is for diagnosis, screening, and
patient management.
Comment: Clinical laboratory tests are used by the practitioner to (1) aid in
the diagnostic process; (2) screen for early recognition of preventable health problems;
and (3) monitor patient progress and outcomes. It is inappropriate to utilize clinical
laboratory procedures for other purposes (e.g., for defensive testing or economic gain).
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Laboratory Selection
It is recommended that the practitioner who uses the
services of a clinical laboratory should be aware of the laboratory’s scope of
services, recognition (licensure and accreditation), and reputation.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Office Laboratories
The practitioner who performs office laboratory procedures
should carry out testing in a manner that meets state and/or federal regulations, and is
consistent with quality laboratory practice.
Comment: State and federal regulations define the scope of testing,
qualification of laboratory personnel, and the need and extent of quality assurance and
proficiency testing.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Proper Patient Preparation
The practitioner should make sure the patient is
adequately prepared for laboratory testing, verifying that the patient understands any
special instructions to assure adequate specimens necessary to generate valid laboratory
results.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Specimen Collection and Preservation
The practitioner should assure that
in-office laboratory specimens are appropriately collected and preserved.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
The Need for Laboratory Testing
Laboratory procedures may be appropriate when the
information available from the history, clinical examination, and previous evaluation is
considered insufficient to address the clinical questions at hand.
Comment: The decision to order and/or perform a given test or procedure is made
on the assumption that the results will appreciably reduce the uncertainty surrounding a
given clinical question and significantly change the pre-test probability that the
disorder is present.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Laboratory Test Selection in Diagnosis
The practitioner should select a
laboratory test(s) appropriate for the purpose of ruling out a specific condition(s) or
confirming a strong clinical suspicion by considering the sensitivity and specificity of
the test(s) and estimating the likelihood of the condition(s) (pretest probability) based
on his or her assessment of the available clinical information.
| Rating: |
Promising |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Laboratory Test Selection in Screening
The use of laboratory tests for screening
purposes should include selection of a highly sensitive laboratory test(s) and the
appropriate application of the test(s) to health problem(s) which are common, have
significant morbidity/mortality and are preventable and/or amenable to effective care.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Laboratory Test Selection in Patient Management (Monitoring)
The reproducibility
(precision) of the test is the most important characteristic when selecting laboratory
tests for monitoring.
Comment: The optimal frequency for monitoring patients cannot be predicted
solely on the basis of knowledge of the disorder or the effectiveness of chiropractic
care. It requires the application of normal physiology, knowledge of the natural history
of the underlying disorder, tests or procedures used to monitor the disorder and awareness
of factors other than the disorder that may influence the test results.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Interpretation of Laboratory Reference Values
The practitioner should have an
understanding of "normality" as it applies to conventional laboratory reference
values in order to appropriately interpret laboratory results.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Integration of Clinical Laboratory Data with Other Examination Findings
Clinical
laboratory data should be integrated with results from other examinations as part of the
clinical decision-making process when monitoring the patient’s clinical status.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Communication of Laboratory Procedures and Results to the Patient
The
practitioner should effectively discuss with the patient the purposes, possible
complications, and clinical significance of the results of laboratory studies conducted or
ordered.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Recording Laboratory Results:
Clinical laboratory results should be recorded in
the patient case record.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Consultation on Laboratory Procedures
The practitioner should seek assistance
when uncertain about appropriate test selection, patient preparation, and/or
interpretation of laboratory results.
| Rating: |
Established |
| Evidence: |
Class III |
| Consensus Level: |
1 |
Use of Focused Organ/Health Problem-Oriented Test Profiles
The use of profiles
which focus on an organ system and/or health problem in a symptomatic patient can be
considered a cost-effective and efficient procedure for generating appropriate laboratory
data to help confirm or rule out a diagnosis or clinical impression.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Use of Investigational Laboratory Tests
Laboratory tests which are considered to
be investigational should be used in clinical settings only when part of an acceptable
research protocol which is supervised by the staff of a recognized research institution.
Comments: Research protocols for the evaluation of investigational clinical
laboratory tests should take into consideration the actual need for the tests, the
inherent properties of the tests, the population characteristics to which the tests are
applied, the existence of gold standard tests, the required study population size, and the
tests’ discrimination abilities relative to sensitivity, specificity, and predictive
value (Adams, 1990). Research protocols should be approved by an institutional review
board.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
The Novel Application of Established Laboratory Procedures in Chiropractic Practice
Novel
application of established laboratory procedures should not be used in chiropractic
practice as a substitute for conventional application of laboratory procedures in the
clinical decision-making process.
Comment: Novel applications of established tests should be evaluated by
appropriate research methods. If used in a patient care setting, informed consent is
necessary.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Commonly Utilized Laboratory Procedures
Guidelines for Ordering a Urinalysis
Outpatient Screening/Case-Finding
i. A urinalysis is not indicated in
asymptomatic individuals whose history and physical examination findings are within the
normal ranges for age and sex.
ii. In specific subsets of the population with higher prevalence of renal disease,
urinary tract infections, liver disease, and diabetes mellitus, the urinalysis may be
useful to identify those who are significantly at risk, including but not limited to the
following:
Pregnancy
Elderly (> 60 years) men and women
Obese individuals with a positive family history of diabetes mellitus
Individuals taking hepato- or nephrotoxic drugs
Individuals routinely exposed to toxic chemicals in the work or home environment
Diagnosis
i. The urinalysis is indicated in patients where there are clinical
findings suggestive of urinary tract infections, renal disease, diabetes mellitus, and
liver disease. The urinalysis should include physical, chemical, and microscopic
evaluation.
ii. The urinalysis may be useful in patients with previous positive findings for
proteinuria, microhematuria, bacteriuria, pyuria, or diabetes mellitus.
Monitoring
i. Repeat urinalysis is not indicated in patients in whom no
abnormality is suspected.
ii. Repeat urinalysis may be useful in the following:
Documenting evidence of response to treatment for urinary tract infections, renal
disease, and diabetes mellitus
Patients in whom there is concern that treatment has not been effective
Patients taking medications which are hepato- or nephrotoxic
Individuals routinely exposed to toxic chemicals
Pregnancy
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Complete Blood Count (CBC)
Outpatient Screening/Case-Finding
i. CBCs are not indicated in asymptomatic
individuals whose history and physical examination findings are within reference for age
and sex.’
ii. In specific subsets of the population with higher prevalence of anemia, the CBC may
be useful to identify those who are significantly anemic because of poor nutrition or
undiagnosed chronic illness, including but not limited to the following:
Pregnant women in whom there is a suspicion that iron supplementation or nutrition has
not been adequate
The elderly (>75 years old)
Recent immigrants from Third World countries, especially persons at increased risk of
malnourishment
Individuals on diets which are nutritionally unbalanced
Diagnosis of Suspected Abnormality
i. The CBC is useful in the diagnosis of
infection or primary hematological disorders.
The CBC is indicated in patients in whom there are clinical findings suggestive of
anemia, including fatigue, mucous-membrane pallor, sore tongue, peripheral neuropathy,
abnormal bleeding, or findings suggestive of polycythemia
ii. The CBC may be useful in conditions that may be associated with anemia and/or
abnormal leukocyte counts, such as rheumatoid arthritis, malignancy (e.g., lymphoma)and
renal insufficiency.
iii. The CBC may be useful when fever is present or when infection is suspected,
especially when other confirmatory findings are absent.
Monitoring
i. Repeat CBCs are not indicated in patients in whom no abnormality is
suspected.
ii. Repeat CBCs may be useful in the following:
Patients in whom there is concern that treatment has not been effective
Documenting evidence of response to treatment for anemia
Patients with infection not improving clinically under collaborative care
Patients with leukopenia (leukocyte count is less than 4,500/j.d)
Patients taking cytotoxic medications
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering the Erythrocyte Sedimentation Rate (ESR) Test
Outpatient Screening/Case-Finding
i. The ESR is not indicated in asymptomatic
persons.
ii. An ESR should be ordered/performed selectively and interpreted with caution in
patients whose symptoms are not adequately explained by a careful history and physical
examination.
Significant infections or inflammatory or neoplastic disease are unlikely in such
patients, and the ESR must be markedly elevated to be diagnostically useful.
Extreme elevation of the ESR seldom occurs in patients with no evidence of serious
disease.
Diagnosis
i. The ESR is useful for the diagnosis of temporal arteritis (giant
cell arteritis) and polymyalgia rheumatica.
A normal ESR virtually excludes the diagnosis of temporal arteritis in most patients who
are suspected of having the disease.
When there is strong clinical evidence for temporal arteritis and the ESR is normal,
further efforts to diagnose temporal arteritis are required.
ii. A careful history and physical examination are the most reliable means of making a
diagnosis of rheumatoid arthritis. In patients with an equivocal examination, an ESR may
be indicated and an abnormal result is a clue to the presence of this disease.
iii. The ESR may be indicated in the differential diagnosis of solitary bone lesions.
iv. The ESR may be indicated in the diagnosis of metastatic breast cancer.
v. The ESR may be indicated as a means of excluding suspected vertebral osteomyelitis.
vi. The ESR may assist in the differential diagnosis of certain infectious,
inflammatory, and malignant disorders.
vii. The ESR may provide assistance in distinguishing spinal pain of organic origin
from mechanical origin.
Monitoring
i. The ESR is useful for monitoring temporal arteritis and polymyalgia
rheumatica.
ii. The judicious use of the ESR combined with other clinical and laboratory
observations may be of value in patients with rheumatoid arthritis and systemic lupus
erythematosus.
iii. The ESR may be indicated for monitoring patients with Hodgkin’s disease.
iv. The ESR may be indicated for monitoring patients with acute rheumatic fever.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Biochemical Profiles
Outpatient Screening/Case-Finding
i. Biochemical profiles are not routinely
indicated for screening asymptomatic patients.
ii. Selected components of biochemical profiles may be indicated for screening and/or
case-finding in adults: serum glucose, cholesterol and creatinine.
iii. Specific components of biochemical profiles that are not indicated for screening
include the following: serum calcium, alkaline phosphatase, uric acid, sodium, potassium,
chloride, AST, lactic dehydrogenase (LDH), total protein, albumin, and total bilirubin.
iv. In cases where current technology and/or cost prohibit selective test ordering,
biochemical profiles should be used with caution because of a greater likelihood of
false-positive findings in low disease-prevalent populations.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum or Plasma Glucose Test.
Outpatient Screening/Case-Finding
i. A serum or plasma glucose test is not
routinely indicated to screen for diabetes mellitus in asymptomatic, nonpregnant adults.
ii. A serum or plasma glucose test may be indicated in individuals who are at increased
risk for diabetes mellitus.
Risk factors for diabetes mellitus include age (>50 years), family history in a first
degree relative, personal history of gestational diabetes, body weight that exceeds
generally accepted standards by at least 25 percent, or membership in an ethnic group that
has a high prevalence of diabetes.
iii. A serum or plasma glucose test is recommended for all pregnant women to screen for
gestational diabetes.
Diagnosis
i. A fasting or random plasma glucose measurement is useful for the
diagnosis of diabetes mellitus in persons who present with symptoms of hyperglycemia
(rapid weight loss, polyuria, polydipsia) and/or diabetes (for example, peripheral
neuropathy or peripheral vascular disease).
ii. In patients with clinical findings of hypoglycemia, a serum or plasma glucose
should be ordered.
The true hypoglycemia syndrome refers to the presence of adrenergic (sweating, tremor,
tachycardia, anxiety, and hunger) or neuroglycopenic (dizziness, headache, clouded vision,
blunted mental acuity, confusion, abnormal behavior, coma) signs and symptoms in the
presence of a low serum or plasma glucose concentration.
Monitoring
i. A plasma or serum glucose test is not optimal as the primary
modality for monitoring glycemia in insulin-dependent (Type I) diabetic patients with
diabetes.
ii. In non-insulin dependent (Type II) diabetes, laboratory performed plasma or serum
glucose testing may be indicated every three months.
Self-monitored blood glucose measurement may be indicated one or two times per day to
assess glycemia
Glycated hemoglobin measurements are indicated at least two times per year to provide an
index of mean glucose levels as a measure of overall chronic glucose control
iii. Laboratory performed fasting and postprandial plasma glucose measurements are
indicated in diet-treated gestational diabetes every one to two weeks from time of
diagnosis until 30 weeks’ gestation, and once or twice weekly thereafter.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Serum Urea Nitrogen and Creatinine Test
Outpatient Screening/Case-Finding
i. Serum urea nitrogen and creatinine tests are
not indicated in asymptomatic individuals whose history and physical examination findings
are within reference ranges.
ii. Individuals who have a higher likelihood of developing renal dysfunction may
benefit from measuring serum urea nitrogen and creatinine concentrations
Patients with hypertension, diabetes mellitus, congestive heart failure, cirrhosis,
prostatic hypertrophy, exposure to nephrotoxic agents, taking diuretics, eating a
high-protein diet, and over 75 years of age, are candidates for these tests.
Diagnosis
i. Serum urea nitrogen and creatinine tests are useful in the diagnosis
of renal disorders.
These tests are indicated in patients with clinical findings suggestive of renal
dysfunction, such as pallor, anemia, anorexia, unexplained weight loss, polyuria, urinary
hesitancy, nocturia, renal colic, dehydration, retinopathy, hypertension, skin lesions of
vasculitis, and/or an abnormal urinalysis (high specific gravity, proteinuria, hematuria,
pyuria, presence of crystals and/or casts).
ii. Measuring serum urea nitrogen and creatinine concentration, or creatinine alone,
may be useful in hypertension or diabetes patients.
iii. Conditions in which both the serum urea nitrogen and creatinine concentration may
be indicated include but are not limited to the following:
Gastrointestinal bleeding, complicated by some degree of renal insufficiency
A suspected diagnosis of water intoxication
Syndrome of inappropriate antidiuretic hormone secretion
Monitoring
i. Measuring serum urea nitrogen and serum creatinine concentration,
or creatinine alone, may be useful for the following conditions and at the following
frequencies:
Uncomplicated hypertensive patients, every one to two years
Chronic renal disease, every four to six months
Patients in acute renal failure, every one to two days
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum Calcium Test
Outpatient Screening/Case-Finding
i. The serum calcium test is not indicated in
asymptomatic individuals whose history and physical examination findings are within
reference limits for age and sex.
ii. The use of serum calcium as a screening test for occult metabolic bone disease or
malignancy will result in a low diagnostic yield.
Diagnosis
i. The serum calcium test is useful in the evaluation of patients who
present with clinical evidence of hypercalcemia (anorexia, nausea, constipation, polyuria,
polydipsia, bone pain, and mental or neurologic aberrations) or hypocalcemia
(paresthesias, muscle cramps, tetany, weakness, convulsions).
ii. The serum calcium test may be useful in the evaluation of patients with
hypertension, renal calculi, peptic ulcer disease, metabolic bone disease, malignant
disorders, history of previous neck surgery, alcoholism, and acid-base imbalance.
Monitoring
i. Repeat serum calcium measurement is not indicated in patients in
whom no abnormality is suspected.
ii. Serum calcium may be used to follow the course of hypercalcemia and hypocalcemic
disorders and their response to care.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum Inorganic Phosphorus Test
Outpatient Screening/Case-Finding
i. The serum inorganic phosphorus test is not
indicated in asymptomatic individuals whose history and physical examination findings are
within reference limits for age and sex.
ii. The use of serum inorganic phosphorus as a screening test for various malignant,
inflammatory, bony, renal and metabolic disorders will result in a low diagnostic yield.
Diagnosis
i. The serum inorganic phosphorus test is useful in the evaluation of
patients suspected of having metabolic bone disease, renal disorders, endocrime disorders,
and acid-base imbalance.
Monitoring
i. Repeat serum inorganic phosphorus measurement is not indicated in
patients in whom no abnormality is suspected.
ii. Serum inorganic phosphorus may be used to follow the course of hyperphosphatemic
and hypophosphatemic disorders and their response to care.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Serum Total Protein and Albumin Test
Outpatient Screening/Case-Finding
i. The serum total protein and albumin tests
are not indicated in asymptomatic individuals whose history and physical examination
findings are within reference limits for age and sex.
ii. The use of serum total protein and albumin as screening tests for malnutrition,
protein loss or breakdown, and impaired protein synthesis will result in a low diagnostic
yield.
Diagnosis
i. The serum total protein and albumin tests may be useful in the
evaluation of patients with suspected malnutrition, liver disorders, renal disease,
malabsorption, recurrent infections, blood dyscrasias, and malignancies such as multiple
myeloma.
ii. Results which fall outside the reference range for these tests may require a
protein electrophoresis determination and/or immunoelectrophoresis.
Monitoring
i. Repeat serum total protein and albumin measurements are not
indicated in patients in whom no abnormality is suspected.
ii. Serum total protein and albumin determinations have limited value in monitoring
disorders associated with changes in serum protein levels.
| Rating: |
Established |
| Evidence: |
Class II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum Cholesterol Test
Outpatient Screening/Case-Finding
i. A total serum cholesterol measurement is
recommended at least once in early adulthood and at intervals of five or more years up to
age 70.
ii. In patients who demonstrate risk factors for coronary artery disese, a serum total
cholesterol is indicated to assess cardiac risk.
Risk factors for coronary artery disease include: being male or postmenopausal female,
positive family history, smoker, hypertension, history of hyper-cholesterolemia, low
HDL-cholesterol levels, diabetes mellitus, previous stroke, peripheral vascular disease,
or severe obesity.
Diagnosis
i. The total serum cholesterol is useful in the diagnosis of patients
with coronary artery disease and peripheral vascular disease.
ii. The total serum cholesterol may be useful in the diagnosis of nephrotic syndrome,
pancreatitis, and liver disease.
Monitoring
i. Total serum cholesterol may be used to follow up
hypercholesterolemic related disorders and their response to care.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum Alkaline Phosphatase Test
Outpatient Screening/Case-Finding
i. The serum alkaline phosphatase test is not
indicated in asymptomatic individuals whose history and physical examination findings are
within reference limits for age and sex.
ii. The use of serum alkaline phosphatase as a screening test for unsuspected skeletal
and hepatobiliary diseases provides a low diagnostic yield.
The pretest probability is low in the general population for those disorders most
strongly associated with an elevated alkaline phosphatase.
The serum alkaline phosphatase test is not specific for any particular disorder or
sensitive enough to identify most patients with any single disease.
Diagnosis
i. The serum alkaline phosphatase may be useful in the evaluation of
patients who present with clinical evidence of a skeletal disorder with increased
osteoblastic activity, and are suspected of having either Paget’s disease of bone
(osteitis deformans), osteomalacia, primary bone tumors, metastatic bone tumors or primary
hyperparathyroidism.
Clinical evidence may include backache, bone pain, bone swelling, abnormal plain film
bone radiographs, and bone scans.
ii. The serum alkaline phosphatase test may be useful in the evaluation of patients who
present with clinical evidence of a hepatobiliary disorder such as cholelithiasis with
obstruction, drug-induced cholestasis, metastatic tumor or space-occupying lesion in the
liver, cirrhosis, hepatitis, and alcoholism.
Clinical evidence may include fever, nausea, vomiting, abdominal pain, jaundice, certain
medication use, and abnormal liver function tests.
iii. The serum alkaline phosphatase test may exhibit abnormal results in a number of
other disorders.
These conditions include intestinal disorders, malignancy, malnutrition, congestive
heart failure, renal disorders, thyroid dysfunction, diabetes mellitus, and physiological
influences (age, pregnancy, non-fasting patient).
Monitoring
i. Repeat serum alkaline phosphatase measurement is not indicated in
patients in whom no abnormality is suspected.
ii. Periodic determinations of serum alkaline phosphatase may be used to follow the
course of a disorder and its response to care.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Serum Prostatic Acid Phosphatase
Outpatient Screening/Case-Finding
i. The serum prostatic acid phosphatase test is
not indicated in asymptomatic individuals whose history and physical examination findings
are within reference limits for age and sex.
ii. The use of serum prostatic acid phosphatase as a screening test for unsuspected
cancer of the prostate provides a low diagnostic yield.
Assays for serum prostatic acid phosphatase are not sufficiently sensitive to detect
prostatic carcinoma in 70 to 80 percent of patients with localized disease (Stage A or B)
or S to 15 percent of patients with metastatic prostatic disease.
Specificity is low because nearly every method devised for detecting prostatic acid
phosphatase exhibits cross-reactivity with other acid phosphatase isoenzymes found widely
in human tissues.
Diagnosis
i. The serum prostatic acid phosphatase test may be useful in the
evaluation of patients with clinical evidence of prostatic carcinoma.
Patients may present with obstructive symptoms (hesitancy, diminished urine stream,
dribbling, intermittency), lumbar and/or sacral pain, and have induration or nodular
irregularities of the prostate discovered by digital rectal examination.
Monitoring
i. Repeat serum prostatic acid phosphatase measurement is not
indicated in patients in whom no abnormality is suspected.
ii. Serum prostatic acid phosphatase measurement may be used to monitor cancer patients
for recurrence after prostatectomy or other ablative care.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Serum Prostate-Specific Antigen (PSA)
Outpatient Screening/Case-Finding
i. The serum prostate-specific antigen (PSA)
test is not indicated in asymptomatic individuals whose history and physical examination
findings are within reference limits for age and sex.
ii. The use of serum PSA as a screening test for unsuspected cancer of the prostate
provides a low diagnostic yield.
Serum PSA measurements are not sufficiently sensitive to be used alone as a screening
test.
The specificity of PSA is limited, due to elevations of the antigen occurring in men
with benign prostatic hyperplasia or prostatitis.
Diagnosis
i. The serum prostate-specific antien is a useful test in the
evaluation of patients with clinical evidence of prostatic carcinoma.
Serum PSA measurement is a useful addition to rectal examination and ultrasonography in
the detection of prostate cancer.
PSA is more sensitive but less specific than prostatic acid phosphatase for prostatic
cancer.
Monitoring
i. Repeat serum prostate-specific antigen measurement is not indicated
in patients in whom no abnormality is suspected.
ii. Serum PSA measurements may be useful to detect recurrences of prostate cancer.
iii. Serum PSA measurements may be useful in monitoring the response to care for
prostate cancer.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum Aspartate Aminotransferase (AST) Test
NOTE:
This
test was formerly known as glutamic-oxaloacetic transaminase (SGOT).
Outpatient Screening/Case-Finding
i. The serum AST is not indicated in
asymptomatic individuals whose history and physical examination findings are within
reference limits for age and sex.
ii. The use of serum AST as a sreening test for liver disorders, cardiac disease, and
skeletal muscle disorders will result in a low diagnostic yield.
Diagnosis
i. The serum AST test may be useful in the evaluation of patients with
suspected liver disorders.
Monitoring
i. Repeat serum AST measurement is not indicated in patients in whom
no abnormality is suspected.
ii. Serum AST may be used to follow the course of various liver disorders and their
response to care.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Serum Creatine Kinase (CK)
NOTE:
This test was formerly
known as Creatine Phosphokinase (CPK).
Outpatient Screening/Case-Finding
i. The serum creatine kinase (CK) test is not
indicated in asymptomatic individuals whose history and physical examination findings are
within reference limits for age and sex.
ii. The use of the serum creatine kinase (CK) as a screening test for cardiac, skeletal
muscle, and central nervous system disorders will result in a low diagnostic yield.
Diagnosis
i. The serum creatine kinase (CK) test is useful in the evaluation of
patients who present with clinical evidence of acute myocardial infarction.
ii. The serum creatine kinase (CK) test may be useful in the differential diagnosis of
chest pain, hypothyroidism and in the detection of skeletal muscle disorders that are not
of neurogenic origin, such as Duchenne Muscular Dystrophy.
Monitoring
i. Measurement of serial levels of serum CK and CK-MB isoenzymes are
used to monitor care in acute myocardial infarction.
ii. Total serum CK may be used to follow patients with certain primary myopathies.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering Thyroid Function Tests
Outpatient Screening/Case-Finding
i. Routine testing for thyroid disorders is not
indicated in asymptomatic individuals.
ii. Case-finding is indicated in women over 50 years of age who have general symptoms
that could be associated with thyroid dysfunction.
Diagnosis
i. The sensitive thyrotropin assay (sTSH) is useful in the evaluation
of patients of either sex who present with clinical evidence of thyroid dysfunction.
If sTSH is not available, the Free T3, Free T4, or Free T4 Index can be used in the
evaluation of suspected hyperthyroidism.
For the diagnosis of hypothyroidism, the Free T4 or Free T4 Index, followed by a serum
thyrotropin (TSH) test, is acceptable. For patients suspected of having thyroiditis,
antithyroid antibody studies may be useful.
Monitoring
i. The sTSH test is indicated for monitoring patient response to care.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
| Consensus Level: |
1 |
Guidelines for Ordering a Serum Uric Acid Test
Outpatient Screening/Case-Finding
i. The serum uric acid test is not indicated in
asymptomatic individuals whose history and physical examination findings are within
reference limits for age and sex.
ii. The use of serum uric acid as a screening test for gout will provide a low
diagnostic yield.
iii. For case finding, with a pretest probability of 10 percent (prevalence of gout in
the U.S. is estimated at 0.3%), the probability that a correct diagnosis will be derived
from a positive test is less than 50%.
Diagnosis
i. The serum uric acid test is useful in the evaluation of patients who
present with clinical evidence of monoarticular arthritis and are suspected of having
gout.
ii. The serum uric acid test may be elevated in a number of disorders other than gout
which affect urate production or excretion, or both.
These conditions include: (1) increased nucleic acid turnover related to hematological
disorders, malignancy and psoriasis; (2) reduced excretion due to renal dysfunction,
certain drugs, and organic acidosis, and (3) miscellaneous causes such as arteriosclerosis
and hypertension.
iii. Serum uric acid measurement is not useful as a test for renal function because the
reference range is wide and the rise in uric acid in renal dysfunction is not constant.
Monitoring
i. Repeat serum uric acid measurement is not indicated in patients in
whom no abnormality is suspected.
ii. Periodic determinations of serum uric acid may be useful in monitoring patients
under care for gout.
iii. Serial serum uric acid analyses are sometimes of value in estimating prognosis in
toxemia of pregnancy.
| Rating: |
Established |
| Evidence: |
Class I, II, III |
