Residents gather essential and accurate clinical information about the patients on whom they receive clinical consults including (All PGY levels):
Discuss patient history with clinical housestaff and/or attendings.
Review reports of previous laboratory results
Review of the online medical record when applicable.
Follow all patient confidentiality rules per WVUH HIPAA guidelines.
Residents are able to be actively involved with Chem/Immuno consultations and are able to handle clinical questions with increasing degrees of independence including (all PGY Levels):
Researching and reviewing medical information from charts, laboratory information system (LIS) and hospital information system (HIS)
Interpreting Chem/Immuno testing including – but not limited to - cardiac markers, toxicology assays, serum protein electrophoreses (SEP), immunofixation electrophoresis (IFE), L/S ratios, and AFP testing during pregnancy.
Timely and effective communication with clinicians and laboratory staff.
Residents demonstrate competence in the methodology and performance of procedures considered essential for Chem/Immuno practices as outlined in the sections below.
Senior residents (PGY 3-4) are involved in developing and validating new assays in the chemistry and immunology laboratories. Examples of these over the past year include revising our guidelines for glucose tolerance testing and evaluating alternatives to our FLM testing.
Senior residents (PGY 3-4) are more involved with the quality assurance program and have the opportunity to inspect our lab or other labs during CAP inspections. During our last inspection at Geisinger Hospital, a resident was involved in inspecting the chemistry and toxicology labs at that institution.
Automated chemistry testing
Understand the concepts of analytical and clinically reportable range
Review the analytical procedure manuals in the Chemistry Lab for the two major automated instruments (LX20, Centaur)
Describe how reference ranges are established and validated
Interpret results of common laboratory tests
Cardiac marker testing
Describe current diagnostic criteria for myocardial infarction (MI), which includes an understanding of the role of diagnostic modalities (i.e. ECG, laboratory testing, imaging, ect.)
Be familiar with the diagnostic & prognostic significance as well as the limitations of current coronary artery disease biomarkers (Troponins I and T, creatinine kinase including isoforms, myoglobin, and cobalt-bound albumin)
Understand relevant analytical issues regarding assays used to measure cardiac markers (e.g., preferred specimen, interferences such as RF and human anti-mouse monoclonal antibodies, analytical false positives, etc.)
Understand the pathophysiology of congestive heart failure (CHF) and the role of laboratory testing in CHF (BNP and NT-proBNP), along with the limitations of these tests.
Blood gas testing
Understand the principles of partial pressure of gases and the need for an O2 carrier. Be able to describe the alveolar-arterial O2 gradient
Understand the significance of P50, O2 content, O2 capacity, and O2 saturation, and be able to distinguish between O2 sat and PO2
Describe the hemoglobin-oxygen dissociation curve and factors that affect curve and P50
Be familiar with principle of integrated blood gas, electrolyte and CO-Oximetry systems
Define the Henderson-Hasselbach equation.
Understand major clinical disorders of acid-base balance (e.g. metabolic & respiratory acidosis, metabolic & respiratory alkalosis, mixed disorders)
Understand the physiology of normal renal function
Develop a broad appreciation of a wide range of renal diseases (e.g., pre-renal azotemia, obstructive azotemia, glomerulonephritis, acute vs chronic renal failure, uremic syndrome)
Become familiar with National Kidney Foundation practice guidelines for these conditions, including the use of estimated glomerular filtration rate (eGFR) in diagnosing and monitoring renal diseases.
Describe laboratory analytical methods (e.g., Jaffe vs creatinase ) used to assess renal function (creatinine, BUN and GFR) and proteinuria
Define osmolality, list molecules in serum that contributes to osmolality, and calculate osmolal gap. Understand the principle of the osmometer.
Liver Function Testing
Understand the dynamics and mechanisms of liver enzyme release, including the clinical utility of liver enzyme testing (e.g., AST, ALT, GGT, NTP, ALP, GGT, LDH)
Understand the biochemical assessment of liver function through non-enzymatic analytes such as albumin, ammonia, bile acids, bilirubin, BUN, cholesterol, total protein, and triglycerides
Be familiar with bilirubin metabolism including:
Fractionation of bilirubin (conjugated, unconjugated, d-bilirubin, direct vs indirect)
Unique aspects of neonatal bilirubin
Conditions and genetic defects that affect bilirubin metabolism, transport and clearance (e.g., Gilbert syndrome, Dubin- Johnson, Rotor’s syndrome, etc.)
Thyroid Function Testing
Understand the structure, biosynthesis, secretion, and metabolism of major thyroid hormones (T4, T3, rT3)
Describe normal thyroid physiology and control of thyroid function, including hormones such as TRH and TSH.
Recognize common causes of hypothyroidism and hyperthyroidism
Interpret laboratory tests of thyroid function
Be familiar with current analytical methods used for thyroid testing (TSH methods, isotopic and nonisotopic methods, T4, free T3 methods, T uptake methods, antimicrosomal/antithyroid peroxidase antibodies assay, thyrotropin-receptor antibodies assay, TSH suppression and stimulation tests, etc)
Pituitary Function Testing
Understand the physiolog action, biochemistry and regulation of anterior pituitary hormones (ACTH, GH, PRL, LH, FSH) and of posterior pituitary hormones (ADH, Oxytocin)
Interpret endocrine tests of hypothalamic-pituitary function (cosyntropin test/rapid ACTH stimulation test, insulin hypoglycemia test, metyrapone test, levodopa test, arginine infusion test, glucose-growth hormone suppression test, TRH test, GnRH test, clomiphene test, CRH test, gonadotropin-releasing hormone test, water deprivation test, saline infusion test and water loading test)
Adrenal Cortical Function Testing
Describe the physiological action, biochemistry, biosynthesis, chemical structure and metabolism of glucocorticoids and mineralocorticoids.
Understand clinical conditions associated with excess and/or deficiency of adrenal cortical hormones. Be familiar with testing the functional status of the adrenal cortex (basal levels vs. stimulation tests & suppression tests, circadian rhythm of corticosteroids, morning ACTH, cortisol [urinary, random and free], rapid ACTH Cortisol stimulation test, multi-day ACTH stimulation, metyrapone stimulation, CRH stimulation)
Gastric Pancreatic and Intestinal Function Testing
Be familiar with clinical manifestations of gastric, pancreatic & intestinal disease and diagnostic methodologies such as breath tests for H. pylori, fecal occult blood, lipase amylase (fractionation of amylase; pancreatic versus salivary and amylase/creatinine clearance ratio)
Glucose monitoring and diabetic testing
Understand the metabolism of carbohydrates (insulin, C-peptide and other regulatory hormones)
Be familiar with the American Diabetes Association (ADA) definitions of impaired fasting glucose and diabetes mellitus Type I & Type II
Describe the laboratory assessment of diabetes and glucose metabolism (blood glucose, oral glucose tolerance test, Hb A1c, fructoseamine and urinary microalbumin)
Mineral and Bone Metabolism
Understand the biochemistry and physiology of calcium, phosphate, and magnesium
Recognize physiological states of calcium, phosphate, and magnesium (free ionized, protein-bound, complexed and total) and factors that affect these states (pH, protein concentrations, etc)
Be familiar with hormones that regulate mineral metabolism (PTH, calcitonin, vitamin D, PTHrP, etc)
Understand various PTH assays including “bio-intact” PTH and intra-operative PTH testing
Interpret laboratory evaluations of metabolic bone diseases such as osteoporosis, osteomalacia and Paget’s disease
Porphyrins and Disorders of Porphyrin Metabolism
Be familiar with the chemistry, biochemistry and biosynthesis of heme and porphyrins. This includes the enzymes involved in heme and porphyrins biosynthesis
Be familiar with porphyrin disorders such as primary porphyrin disorders including neurological/psychiatric vs. cutaneous photosensitivity as well as secondary or acquired porphyrin disorders
Recommend screening and diagnostic tests for disorders of porphyrin metabolism
Be familiar with the definition, classification, biochemistry and distribution of tumor markers including: PSA, prostatic acid phosphatase, alkaline phosphatase, NSE, calcitonin, HCG, adrencorticotropic hormone, α-fetoprotein, CEA, tissue polypeptide antigen, CA 15-3, CA 27,29, CA 125, CA 19-9, CA-50, CA 72-4, CA 242, NWP22 and receptors (ER and PR)
Know the laboratory assessment of various tumor markers and factors affecting the results
Understand the conceptual basis of assays used to screen for malignancy (limits of sensitivity and specificity using Bayes theorem)
Fetal Lung Maturity
Understand the physiology of respiratory distress syndrome (RDS)
Be familiar with fetal lung maturity testing (lecithin/sphingomyelin (L/S) ratio, phosphatidyl glycerol (PG), foam stability index (FSI or shake test), DSPC, Fluorescence polarization, Counting of lamellar bodies).
Understand the biochemistry, physiology and diagnostic performance of fetal fibronectin
Understand the biochemistry, physiology and metabolism of trace elements (iron, magnesium, zinc, copper, manganese, molybdenum, selenium, cobalt and fluoride) as well as ultratrace elements (nickel, vanadium, boron and silicon)
Describe the biochemistry and clinical significance of metal binding proteins such as transferrin, ferritin and ceruloplasmin
Know the clinical assessments of trace elements (e.g., serum iron, iron binding capacity, transferrin, transferrin saturation, serum ferritin, zinc protoporphyrin, serum ceruloplasmin)
Recognize the specimen of choice (plasma, urine, hair, nail) and the analytical methods for determining trace element level
Define and classify major vitamins including fat soluble vitamins (A, D, E, K) and water soluble vitamins (B1, B2, B6, B12, C, niacin, nicotinamide, folic acid, biotin, panothenic acid)
Understand the clinical disorders associated with the deficiency as well as toxicity of these vitamin
Cholesterol & Lipids Testing
Be familiar with the chemical structures, biosynthesis, classification, functions and metabolism of lipids and lipoproteins
Be familiar with Fredrickson classification and ATP III classification of hyperlipidemia
Understand the pathophysiology of lipid disorders
Describe principles of analytical techniques used to assess lipids
Understand the principles of protein analysis in body fluids (e.g., Kjeldahl and Biuret methods, refractometry, qualitative dipstick).
Be familiar with the principles of serum, urine, CSF and pleural fluid protein electrophoresis including:
Identifying various proteins and interpreting the significance of findings (e.g., monoclonal gammopathy, light-chain diseases, Bence-Jones proteinuria, Oligoclonal banding, proteinuria, etc.).
Recognizing the significance of CSF/serum albumin index, CSF IgG index)
Transudates versus exudates in peritoneal fluid
Pleural/serum protein ratio, pleural fluid LDH and protein, glucose, pH, and lipids of pericardial fluid
Clinical Enzyme Kinetics
Understand the principles of enzyme kinetics (Michaelis-Menten equation, concepts of Km, Vmax. Zero-order and 1st-order kinetics)
Clinical enzymology including isoenzymes and isoforms
Be familiar with the principles of analytical enzymology and know the concepts of activity vs. mass assays (e.g. CK versus CK-MB assays)
Therapeutic Drug Monitoring – General
Understand basic pharmacokinetic principles involving Vd, dose, peak and trough concentration of a drug, area under the curve (AUC), clearance, half-life, bioavailability and protein binding.
Be familiar with one compartmental and two compartmental model of drug distribution, first and second order elimination kinetics and effect of disease on K, the elimination rate constant.
Recognize effects of disease such as uremia, hepatic disease on protein binding of drugs.
Understand common drug-drug interactions with particular emphasis on effect of one drug on clearance of another drug, for example increased clearance of phenytoin in the presence of carbamazepine, an inducer of cytochrome P 450 enzymes, digoxin-quinidine interactions, etc.
Understand which free/unbound drugs are frequently measured and why.
List common factors affecting free/unbound drug levels.
Therapeutic Drug Monitoring of Specific Drugs
Analgesics/Antipyretics: Toxic levels of acetaminophen and salicylate. Liver failure due to acetaminophen overdose and specific antidote for treatment.
Antidepressants: (Tricyclic antidepressants, selective serotonin reuptake inhibitors). Limitation of immunoassays for tricyclic antidepressant for therapeutic drug monitoring due to cross-reactivity of active metabolites.
Anticonvulsants: Familiar with therapeutic drug monitoring of classical antidepressants such as phenytoin, carbamazepine, Valproic acid, Phenobarbital, primidone and ethosuximide. Understand clinical utility of monitoring free phenytoin, free valproic acid and free carbamazepine concentrations in patients with uremia, hepatic disorder, AIDS hypoalbuminemia, and other conditions. Understand the need for therapeutic drug monitoring of newer anticonvulsant such as lamotrigine, gabapentene, oxcarbazepine and tiagabine.
Cardiovascular drugs: Therapeutic drug monitoring of digoxin and effect of endogenous digoxin-like immunoreactive factors on various immunoassays used for monitoring serum digoxin concentrations. Understand therapeutic drug monitoring of lidocaine, tocainide, mexiletine, and quinidine.
Antibiotics: Understand need for monitoring of both peak and trough concentrations of aminoglycosides and vancomycin.
Immunosuppressants: Proficiency in therapeutic drug monitoring of cyclosporine and tacrolimus with understanding of C0, C2 and AUC monitoring for cyclosporine. Be familiar with therapeutic drug monitoring of newer immunosuppressants such as sirolimus and mycophenolic acid.
Clinical and Forensic Toxicology
Understand drug screenings and confirmation (Immunoassays v GC/MS).
Be familiar with alcohol poisoning with ethanol, methanol, isopropanol, and ethylene glycol. Understand DWI laws and legal limit of blood alcohol concentration (0.08% plasma in certain states and whole blood in others)
Be familiar with atomic absorption or mass spectrometric technique for determination of heavy metals in body fluids such as lead, mercury, arsenic, cadmium and others.
Understand pathophysiology of cyanide and carbon monoxide poisoning.
West Virginia University
School of Medicine
1 Medical Center Drive
P.O. Box 9100
Morgantown, WV 26506-9600