LUMBAR PUNCTURE

Lumbar puncture is a procedure that is often performed in the emergency department to obtain
information about the cerebrospinal fluid (CSF).[1, 2, 3, 4]Although usually used for diagnostic purposes to rule
out potential life-threatening conditions (eg, bacterial meningitis or subarachnoid hemorrhage), it is also
sometimes used for therapeutic purposes (eg, treatment of pseudotumor cerebri). CSF fluid analysis can
also aid in the diagnosis of various other conditions (eg, demyelinating diseases and carcinomatous
meningitis).
Lumbar puncture should be performed only after a neurologic examination but should never delay
potentially life-saving interventions, such as the administration of antibiotics and steroids to patients with
suspected bacterial meningitis.[5]

Relevant Anatomy
The lumbar spine consists of 5 moveable vertebrae numbered L1-L5.The lumbar vertebrae have a
vertical height that is less than their horizontal diameter. They are composed of the following 3 functional
parts:

The vertebral body, designed to bear weight

The vertebral (neural) arch, designed to protect the neural elements
The bony processes (spinous and transverse), which function to increase the efficiency of muscle
action
The lumbar vertebral bodies are distinguished from the thoracic bodies by the absence of rib facets. The
lumbar vertebral bodies (vertebrae) are the heaviest components, connected together by the
intervertebral discs. The size of the vertebral body increases from L1 to L5, indicative of the increasing
loads that each lower lumbar vertebra absorbs. Of note, the L5 vertebra has the heaviest body, smallest
spinous process, and thickest transverse process.
For more information about the relevant anatomy, see Lumbar Spine Anatomy.

Indications
Lumbar puncture should be performed for the following indications:

Suspicion of meningitis
Suspicion of subarachnoid hemorrhage (SAH)
Suspicion of central nervous system (CNS) diseases such as Guillain-Barr syndrome[6] and
carcinomatous meningitis
Therapeutic relief of pseudotumor cerebri[7]

Contraindications
Absolute contraindications for lumbar puncture are the presence of infected skin over the needle entry
site and the presence of unequal pressures between the supratentorial and infratentorial compartments.
The latter is usually inferred from the following characteristic findings on computed tomography (CT) of
the brain:

Midline shift
Loss of suprachiasmatic and basilar cisterns
Posterior fossa mass
Loss of the superior cerebellar cistern
Loss of the quadrigeminal plate cistern
Relative contraindications for lumbar puncture include the following:
Increased intracranial pressure (ICP)
Coagulopathy
Brain abscess

Indications for performing brain CT scanning before lumbar puncture in patients with suspected meningitis
include the following[8] :

Patients who are older than 60 years

Patients who are immunocompromised
Patients with known CNS lesions
Patients who have had a seizure within 1 week of presentation
Patients with an abnormal level of consciousness
Patients with focal findings on neurologic examination
Patients with papilledema seen on physical examination, with clinical suspicion of an elevated
ICP
Cranial CT scanning should be obtained before lumbar puncture in all patients with suspected SAH in
order to diagnose obvious intracranial bleeding or any significant intracranial mass effect that might be
present in awake and alert SAH patients with a normal neurologic examination. [9, 10]

Technical Considerations
Complication prevention
The following measures should be taken to help minimize complications of lumbar puncture:

Explain the procedure, benefits, risks, complications, and alternative options to the patient or the
patients representative, and obtain a signed informed consent

Before performing the lumbar puncture, ensure that patients are hydrated so as to avoid a dry tap

Never allow a lumbar puncture or a prelumbar puncture CT scan to delay administration of

intravenous (IV) antibiotics; meningitis can usually be inferred from the cell count, antigen detection, or
both

Avoid lumbar puncture in patients in whom the disease process has progressed to the neurologic
findings associated with impending cerebral herniation (ie, deteriorating level of consciousness and
brainstem signs that include pupillary changes, posturing, irregular respirations, and very recent
seizure)[11, 12]
The smaller the needle used for the lumbar puncture, the lower the risk that the patient will experience a
postlumbar puncture headache. Data suggest an inverse linear relation between needle gauge and
headache incidence, and some authors recommend using a 22-gauge needle regardless of what size
needle is supplied with the kit.[13]
The use of atraumatic needles has been shown to significantly reduce the incidence of postlumbar
puncture headache (3%) when compared to the use of standard spinal needles (approximately 30%). [14,
15]
In addition, it may lead to cost savings. [16] However, obtaining pressures can be more difficult with
atraumatic needles.
Prophylactic bed rest after lumbar puncture has not been shown to be of benefit and should not be
recommended.[17, 18, 19]

ELECTROMYOGRAPHY
Electromyography (EMG) is a technique for evaluating and recording the electrical activity
produced by skeletal muscles.[1] EMG is performed using aninstrument called an electromyograph,
to produce a record called anelectromyogram. An electromyograph detects the electrical
potentialgenerated by muscle cells[2] when these cells are electrically or neurologically activated. The
signals can be analyzed to detect medical abnormalities, activation level, or recruitment order or to
analyze the biomechanics of human or animal movement.

Medical uses[edit]
EMG signals are used in many clinical and biomedical applications. EMG is used as a diagnostics
tool for identifyingneuromuscular diseases, assessing low-back pain, kinesiology, and disorders of
motor control. EMG signals are also used as a control signal for prosthetic devices such as
prosthetic hands, arms, and lower limbs.
EMG then acceleromyograph may be used for neuromuscular monitoring in general anesthesia
with neuromuscular-blocking drugs, in order to avoid postoperative residual curarization (PORC).[3][4][5]
[6]

Electromyography and nerve conduction studies (NCS) measure nerve and muscle function, and
may be indicated when there is pain in the limbs, weakness from spinal nerve compression, or
concern about some other neurologic injury or disorder.[7] Spinal nerve injury does not cause neck,
mid back pain or low back pain, and for this reason, evidence has not shown EMG or NCS to be
helpful in diagnosing causes of axial lumbar pain, thoracic pain, or cervical spine pain.[7]

Technique[edit]

Skin preparation[edit]
The first step before sensor placement is skin preparation. This includes shaving any excess hair
and cleaning the skin with an alcohol pad; abrasion of the skin is also a common step. The goal of all
of these steps is to allow for better adhesion of the electrode and the reduction of skin electrical
resistance. After the skin preparation, an adhesive piece usually must be applied to the electrode
before it can be placed on the skin. Commercial electrodes often have adhesives surrounding the
conductive surface of the electrode.[1]184
The actual placement of the electrode can be difficult and depends on a number of factors, such as
specific muscle selection and the size of that muscle. Proper EMG placement is very important for
accurate representation of the muscle of interest, although EMG is more effective on superficial
muscles as it is unable to bypass the action potentials of superficial muscles and detect deeper
muscles. Also, the more body fat an individual has, the weaker the EMG signal. When placing the
EMG sensor, the ideal location is at the belly of the muscle: the longitudinal midline. The belly of the
muscle can also be thought of as in-between the motor point (middle) of the muscle and the
tendonus insertion point

Surface EMG versus intramuscular[edit]

There are two kinds of EMG in widespread use: surface EMG and intramuscular (needle and finewire) EMG. To perform intramuscular EMG, a needle electrode or a needle containing two fine-wire
electrodes is inserted through the skin into the muscle tissue. A trained professional[citation needed] (such as
a neurologist, physiatrist, chiropractor, or physical therapist) observes the electrical activity while
inserting the electrode.
The insertional activity provides valuable information about the state of the muscle and its
innervating nerve. Normal muscles at rest make certain, normal electrical signals when the needle is
inserted into them. Then the electrical activity when the muscle is at rest is studied. Abnormal
spontaneous activity might indicate some nerve and/or muscle damage. Then the patient is asked to
contract the muscle smoothly. The shape, size, and frequency of the resulting electrical signals are
judged. Then the electrode is retracted a few millimetres, and again the activity is analyzed until at
least 1020 motor units have been collected. Each electrode track gives only a very local picture of
the activity of the whole muscle. Because skeletal muscles differ in the inner structure, the electrode
has to be placed at various locations to obtain an accurate study.
Intramuscular EMG may be considered too invasive or unnecessary in some cases. Instead, a
surface electrode may be used to monitor the general picture of muscle activation, as opposed to the
activity of only a few fibres as observed using an intramuscular EMG. This technique is used in a
number of settings; for example, in the physiotherapy clinic, muscle activation is monitored using
surface EMG and patients have an auditory or visual stimulus to help them know when they are
activating the muscle (biofeedback).

Maximal voluntary contraction[edit]

The basic function of EMG is to see if a muscle is active or inactive. The most common way that can
be determined is by performing a maximal voluntary contraction (MVC) of the muscle that is being
tested. If the action of the muscle is completed, then the muscle is activated. Any signal that comes
from the electrodes signifies that the muscle is active.[12]
Measuring the activation and force output of a muscle contraction is biomechanically assessed
through the use of surface EMG electrodes. This methodology is a non-invasive practice to quantify
the relationship between a specific movement and the activation of the underlying muscle group(s).
The specific amount of force generated by a muscle is also a common use for EMG. Based on the
different muscular efforts, the EMG signals will vary. However, muscle force indication only
represents those muscle fibers that are close to the EMG signals.
Several methods for determining muscle activation are commonly used depending on the
application. The use of mean EMG activation or the peak contraction value is a debated topic. Most

studies commonly use the maximal voluntary contraction as a means of analyzing peak force and
force generated by target muscles. According to the article, Peak and average rectified EMG
measures: Which method of data reduction should be used for assessing core training exercises?,
[13]

concluded that the average rectified EMG data (ARV) is significantly less variable when

measuring the muscle activity of the core musculature compared to the peak EMG variable.
Therefore, these researchers would suggest that ARV EMG data should be recorded alongside the
peak EMG measure when assessing core exercises. Providing the reader with both sets of data
would result in enhanced validity of the study and potentially eradicate the contradictions within the
research.[14][15]

Other measurements[edit]
EMG can also be used for indicating the amount of fatigue in a muscle. The following changes in the
EMG signal can signify muscle fatigue: an increase in the mean absolute value of the signal,
increase in the amplitude and duration of the muscle action potential and an overall shift to lower
frequencies. Monitoring the changes of different frequency changes the most common way of using
EMG to determine levels of fatigue. The lower conduction velocities enable the slowermotor
neurons to remain active.[16]
A motor unit is defined as one motor neuron and all of the muscle fibers it innervates. When a motor
unit fires, the impulse (called an action potential) is carried down the motor neuron to the muscle.
The area where the nerve contacts the muscle is called the neuromuscular junction, or the motor
end plate. After the action potential is transmitted across the neuromuscular junction, an action
potential is elicited in all of the innervated muscle fibers of that particular motor unit. The sum of all
this electrical activity is known as a motor unit action potential (MUAP). This electrophysiologic
activity from multiple motor units is the signal typically evaluated during an EMG. The composition of
the motor unit, the number of muscle fibres per motor unit, the metabolic type of muscle fibres and
many other factors affect the shape of the motor unit potentials in the myogram.
Nerve conduction testing is also often done at the same time as an EMG to diagnose neurological
diseases.
Some patients can find the procedure somewhat painful, whereas others experience only a small
amount of discomfort when the needle is inserted. The muscle or muscles being tested may be
slightly sore for a day or two after the procedure.

Normal results[edit]

Muscle tissue at rest is normally electrically inactive. After the electrical activity
caused by the irritation of needle insertion subsides, the electromyograph should
detect no abnormal spontaneous activity (i.e., a muscle at rest should be electrically
silent, with the exception of the area of the neuromuscular junction, which is, under
normal circumstances, very spontaneously active). When the muscle is voluntarily
contracted, action potentials begin to appear. As the strength of the muscle
contraction is increased, more and more muscle fibers produce action potentials.
When the muscle is fully contracted, there should appear a disorderly group of
action potentials of varying rates and amplitudes (a complete recruitment and
interference pattern).

Abnormal results[edit]
EMG is used to diagnose diseases that generally may be classified into one of the
following categories: neuropathies, neuromuscular junction diseases, and
myopathies.

Neuropathic disease has the following defining EMG characteristics:

An action potential amplitude that is twice normal due to the increased number of
fibres per motor unit because of reinnervation of denervated fibres
An increase in duration of the action potential
A decrease in the number of motor units in the muscle (as found using motor unit
number estimation techniques)
Myopathic disease has these defining EMG characteristics:

A decrease in duration of the action potential

A reduction in the area to amplitude ratio of the action potential
A decrease in the number of motor units in the muscle (in extremely severe cases
only)
Because of the individuality of each patient and disease, some of these
characteristics may not appear in every case.

Abnormal results may be caused by the following medical conditions (please note
this is nowhere near an exhaustive list of conditions that can result in abnormal
EMG studies):

Alcoholic neuropathy
Amyotrophic lateral sclerosis
Anterior compartment syndrome of the lower leg
Axillary nerve dysfunction
Becker's muscular dystrophy
Brachial plexopathy
Carpal tunnel syndrome
Centronuclear myopathy
Cervical spondylosis
Charcot-Marie-Tooth disease
Chronic Immune Demyelinating Poly[radiculo]neuropathy (CIDP)
Common peroneal nerve dysfunction
Denervation (reduced nervous stimulation)
Dermatomyositis
Distal median nerve dysfunction

CT scan
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A computed tomography (CT) scan is an imaging method that uses x-rays to create pictures of crosssections of the body.
Related tests include:

Abdominal CT scan

Cranial CT scan

Lumbosacral spine CT scan

Orbit CT scan

Thoracic CT scan

How the Test is Performed

You will be asked to lie on a narrow table that slides into the center of the CT scanner.
Once you are inside the scanner, the machine's x-ray beam rotates around you. Modern "spiral" scanners
can perform the exam without stopping.
A computer creates separate images of the body area, called slices. These images can be stored, viewed
on a monitor, or printed on film. Three-dimensional models of the body area can be created by stacking
the slices together.
You must stay still during the exam, because movement causes blurred images. You may be told to hold
your breath for short periods of time.
Complete scans usually take only a few minutes. The newest scanners can image your entire body in less
than 30 seconds.
How to Prepare for the Test
Certain exams require a special dye, called contrast, to be delivered into your body before the test starts.
Contrast helps certain areas show up better on the x-rays.
Let your doctor know if you have ever had a reaction to contrast. You may need to take medicines before
the test in order to avoid another reaction.
Contrast can be given several ways, and depends on the type of CT being performed.

It may be delivered through a vein (IV) in your hand or forearm.

It may be given into your rectum using an enema.

You might drink the contrast before your scan. When you drink the contrast depends on the type
of exam being done. The contrast liquid may taste chalky, although some are flavored. The
contrast passes out of your body through your stools.

If contrast is used, you may also be asked not to eat or drink anything for 4-6 hours before the test.
Before receiving the contrast, tell your health care provider if you take the diabetes medication metformin
(Glucophage). People taking this medicine may need to stop temporarily.

Find out if the CT machine has a weight limit if you weigh more than 300 pounds. Too much weight can
cause damage to the scanner.
You will need to remove jewelry and wear a hospital gown during the study.
How the Test Will Feel
Some people may have discomfort from lying on the hard table.
Contrast given through an IV may cause a slight burning feeling, a metallic taste in the mouth, and a
warm flushing of the body. These sensations are normal and usually go away within a few seconds.
Why the Test is Performed
A CT scan creates detailed pictures of the body, including the brain, chest, spine, and abdomen. The test
may be used to:

Diagnose an infection

Guide a surgeon to the right area during a biopsy

Identify masses and tumors, including cancer

Study blood vessels

Normal Results
Results are considered normal if the organs and structures being examined are normal in appearance.
What Abnormal Results Mean
Abnormal results depend on the part of the body being studied. Talk to your health care provider about
questions and concerns.
Risks
Risks of CT scans include:

Allergic reaction to contrast dye

Being exposed to radiation

CT scans expose you to more radiation than regular x-rays. Having many x-rays or CT scans over time
may increase your risk for cancer. However, the risk from any one scan is small. You and your doctor
should weigh this risk against the value of the information that will come from a CT scan.

Some people have allergies to contrast dye. Let your doctor know if you have ever had an allergic
reaction to injected contrast dye.

The most common type of contrast given into a vein contains iodine. If you have an iodine
allergy, type of contrast may cause nausea or vomiting,sneezing, itching,or hives.

If you absolutely must be given such contrast, your doctor may give you antihistamines (such as
Benadryl) or steroids before the test.

Your kidneys help remove iodine out of the body. You may need to receive extra fluids after the to
help flush iodine out of the body if you have diabetes or kidney disease.

Rarely, the dye may cause a life-threatening allergic response called anaphylaxis. If you have any trouble
breathing during the test, tell the scanner operator immediately. Scanners come with an intercom and
speakers, so the operator can hear you at all times.

SYNOVIAL FLUID ANALYSIS

How is it used?
Synovial fluid analysis may be ordered to help diagnose the cause of joint inflammation, pain, swelling, and fluid
accumulation. Diseases and conditions affecting one or more joints and the synovial fluid can be divided into four
main categories:
Infectious diseases those caused by bacteria, fungi, or viruses. They may originate in the joint or spread there from
other places in the body. These conditions include acute and chronic septic arthritis.
Bleeding bleeding disorders and/or joint injury can lead to blood in the synovial fluid. Commonly present in people
with untreated blood clotting disorders such as hemophilia or von Willebrand Disease.
Inflammatory diseases

Conditions that cause crystal formation and accumulation such as gout (needle-like uric acid [monosodium
urate] crystals) and pseudogout (calcium pyrophosphate dihydrate crystals). Typically affect the feet and legs.

Conditions that cause joint inflammation, such as synovitis, or other immune responses. These may
includeautoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus.

Degenerative diseases such as osteoarthritis

^ Back to top

When is it ordered?
Synovial fluid analysis may be ordered when a doctor suspects that a person has a condition or disease involving one
or more of their joints. It may be ordered when someone has some combination of the following signs and symptoms:

Joint pain

Redness over the joint

Joint inflammation and swelling

Synovial fluid accumulation

It may sometimes be ordered to monitor a person with a known joint condition.

^ Back to top

What does the test result mean?

Synovial fluid usually contains a small amount of glucose and protein and may have a few white blood cells (WBCs)
and red blood cells (RBCs).
There are a variety of joint abnormalities including osteoarthritis, rheumatoid arthritis, gout, and infection (septic
arthritis) that can cause inflammation, swelling, an accumulation of synovial fluid, and sometimes bleeding into one or
more joints. These conditions can limit mobility and, if left untreated, may permanently damage the joints.
Results of tests performed on a sample of synovial fluid may include:
Physical characteristics the normal appearance of a sample of synovial fluid is usually:

Straw colored

Clear

Moderately viscous drops of it from a syringe needle will form a "string" a few inches long.

Changes in the physical characteristics may provide clues to the disease present, such as:

Less viscous fluid may be seen with inflammation.

Cloudy synovial fluid may indicate the presence of microorganisms, white blood cells, or crystals.

Reddish synovial fluid may indicate the presence of blood, but an increased number of red blood cells may
also be present in cloudy synovial fluid.

Chemical tests tests that may be performed on synovial fluid samples may include:

Glucosetypically a bit lower than blood glucose levels; may be significantly lower with joint inflammation
and infection.

Proteinincreased with bacterial infection

Uric acidincreased with gout

Microscopic examination Normal synovial fluid has small numbers of white blood cells (WBCs) and red blood
cells (RBCs) but no microorganisms or crystals present. Laboratories may examine drops of the synovial fluid and/or
use a special centrifuge (cytocentrifuge) to concentrate the fluid's cells at the bottom of a test tube. Samples are
placed on a slide, treated with special stain, and an evaluation of the different kinds of cells present is performed.

Total cell countsnumber of WBCs and RBCs in the sample; increased WBCs may be seen with infections
and with conditions such as gout and rheumatoid arthritis.

A WBC differential determines the percentages of different types of WBCs. An increased number
of neutrophils may be seen with bacterial infections. Greater than 2% eosinophils may suggest Lyme disease.

Synovial fluid is evaluated under polarized light to recognize the presence of crystals and to distinguish the
types of crystals that are present. Needle-like monosodium urate crystals are associated with gout and calcium
pyrophosphate crystals are associated with pseudogout.

Infectious disease tests in addition to chemistry tests, other tests may be performed to look for microorganisms if
infection is suspected.

Gram stain allows for the direct observation of bacteria or fungi under a microscope. There should be no
microorganisms present in synovial fluid.

Culture and susceptibility testing is ordered to determine what type of microorganisms are present. If
bacteria are present, susceptibility testing against certain antibiotics can be performed to guide antimicrobial
therapy. If there are no microorganisms present, it does not rule out an infection; they may be present in small
numbers or their growth may be inhibited because of prior antibiotic therapy.

Other tests for infectious diseases that are less commonly ordered include AFB smear and culture. This test
for the presence of mycobacteria may help diagnose tuberculosis. Molecular test methods for Mycobacteria
tuberculosis are more sensitive and specific than traditional cultures and may also be performed.
^ Back to top

Is there anything else I should know?

A blood or urine uric acid or blood glucose may be ordered to compare concentrations with those in the synovial fluid.
If a doctor suspects that a patient may have a systemic infection, then a blood culture may be ordered in addition to
the synovial fluid analysis.
Joint injury, surgery, and joint replacement can increase the risk of developing an infection in a joint.

1. What is arthrocentesis and how is it performed?

Arthrocentesis is the removal of synovial fluid from a joint with a needle and syringe. A local anesthetic is applied and
then the doctor inserts the needle into the space between the bones and collects the synovial fluid.
^ Back to top

2. Are there other reasons to do an arthrocentesis?

Yes. Sometimes it will be performed to drain excess synovial fluid to relieve pressure in the joint and/or to aid in the
treatment of an infection. Sometimes medicines such as corticosteroids will be introduced into the joint to help reduce
inflammation and/or to relieve pain

SERUM CALCIUM

Calcium blood test

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The calcium blood test measures the level of calcium in the blood.
This article discusses the test to measure the total amount of calcium in your blood. About half of the
calcium in the blood is attached to proteins, mainly albumin. For this reason, the calcium blood test can
be misleading, and sometimes needs tests to confirm the result.
A separate test measures calcium that is not attached to proteins in your blood. Such calcium is called
free orionized calcium.
Calcium can also be measured in the urine.
How the Test is Performed
A blood sample is needed.
How to Prepare for the Test
The health care provider may tell you to temporarily stop taking certain medicines that can affect the test.
Medicines include:

Calcium salts (may be found in nutritional supplements or antacids)

Lithium

Thiazide diuretics

Thyroxine

Vitamin D

Drinking too much milk (two or more quarts a day or having an equivalent amount of other dairy
products ) or taking too much vitamin D as a dietary supplement can also increase blood calcium levels.
How the Test will Feel
When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or
stinging sensation. Afterward, there may be some throbbing or slight bruising. These soon go away.
Why the Test is Performed
All cells need calcium in order to work. Calcium helps build strong bones and teeth. It is important for
heart function, and helps with muscle contraction, nerve signaling, and blood clotting.
Your doctor may order this test if you have signs or symptoms of:

Certain bone diseases

Certain cancers, such as multiple myeloma, a cancer of the breast, lung, neck, and kidney

Chronic kidney disease

Chronic liver disease

Disorders of the parathyroid gland

Disorders that affect how your intestines absorb nutrients

Overactive thyroid gland or taking too much thyroid hormone medication

Your doctor may also order this test if you have been on bed rest for a long time.
Normal Risks
Normal values range from 8.5 to 10.2 mg/dL.
Normal value ranges may vary slightly among different laboratories. Some laboratories use different
measurements or may test different specimens. Talk to your doctor about the meaning of your specific
test results.
What Abnormal Results Mean

Higher than normal levels may be due to a number of health conditions. Common causes include:

Being on bed rest for a long time

Consuming too much calcium or vitamin D

HIV/AIDS

Hyperparathyroidism

Infections that cause granulomas such as tuberculosis and certain fungal and mycobacterial
infections

Metastatic bone tumor

Multiple myeloma

Osteomalacia

Overactive thyroid gland (hyperthyroidism) or too much thyroid hormone replacement medication

Paget's disease

Sarcoidosis

Tumors producing a parathyroid hormone-like substance

Use of certain medications such as lithium, tamoxifen, and thiazides

Lower than normal levels may be due to:

Disorders that affect absorption of nutrients from the intestines

Hypoparathyroidism

Kidney failure

Low blood level of albumin

Liver disease

Magnesium deficiency

Osteomalacia

Pancreatitis

Vitamin D deficiency

Risks
There is very little risk involved with having your blood taken. Veins and arteries vary in size from one
patient to another and from one side of the body to the other. Taking blood from some people may be
more difficult than from others.
Other risks associated with having blood drawn are slight but may include:

Excessive bleeding

Fainting or feeling lightheaded

Hematoma (blood accumulating under the skin)

Infection (a slight risk any time the skin is broken)

Multiple punctures to locate veins

SERRUM PHOSPHATASE
Serum alkaline phosphatase measurement
What is this test?
This test measures the amount of alkaline phosphatase (ALP) in blood. It is used to evaluate
bone disease and liver disease[1].
What are other names for this test?

Serum alkaline phosphatase level

What are related tests?

Alkaline phosphatase bone isoenzyme measurement, serum

Hepatic function panel

Hepatobiliary ultrasound

HIDA scan

Radioisotope scan of bone

Why do I need this test?

Laboratory tests may be done for many reasons. Tests are performed for routine health
screenings or if a disease or toxicity is suspected. Lab tests may be used to determine if a
medical condition is improving or worsening. Lab tests may also be used to measure the
success or failure of a medication or treatment plan. Lab tests may be ordered for
professional or legal reasons. The following are possible reasons why this test may be done:

Acute and chronic gallbladder inflammation

Bone metastasis

Drug-induced liver disease

Hepatitis

When and how often should I have this test?

When and how often laboratory tests are done may depend on many factors. The timing of
laboratory tests may rely on the results or completion of other tests, procedures, or
treatments. Lab tests may be performed immediately in an emergency, or tests may be
delayed as a condition is treated or monitored. A test may be suggested or become
necessary when certain signs or symptoms appear.
Due to changes in the way your body naturally functions through the course of a day, lab
tests may need to be performed at a certain time of day. If you have prepared for a test by
changing your food or fluid intake, lab tests may be timed in accordance with those
changes. Timing of tests may be based on increased and decreased levels of medications,
drugs or other substances in the body.
The age or gender of the person being tested may affect when and how often a lab test is
required. Chronic or progressive conditions may need ongoing monitoring through the use of
lab tests. Conditions that worsen and improve may also need frequent monitoring. Certain
tests may be repeated to obtain a series of results, or tests may need to be repeated to
confirm or disprove results. Timing and frequency of lab tests may vary if they are
performed for professional or legal reasons.
How should I get ready for the test?
Before having blood collected, tell the person drawing your blood if you are allergic to latex.
Tell the healthcare worker if you have a medical condition or are using a medication or
supplement that causes excessive bleeding. Also tell the healthcare worker if you have felt
nauseated, lightheaded, or have fainted while having blood drawn in the past.
Fast before this test[2].
How is the test done?
When a blood sample from a vein is needed, a vein in your arm is usually selected. A
tourniquet (large rubber strap) may be secured above the vein. The skin over the vein will
be cleaned, and a needle will be inserted. You will be asked to hold very still while your

blood is collected. Blood will be collected into one or more tubes, and the tourniquet will be
removed. When enough blood has been collected, the healthcare worker will take the needle
out.
How will the test feel?
The amount of discomfort you feel will depend on many factors, including your sensitivity to
pain. Communicate how you are feeling with the person doing the test. Inform the person
doing the test if you feel that you cannot continue with the test.
During a blood draw, you may feel mild discomfort at the location where the blood sample is
being collected.
What should I do after the test?
After a blood sample is collected from your vein, a bandage, cotton ball, or gauze may be
placed on the area where the needle was inserted. You may be asked to apply pressure to
the area. Avoid strenuous exercise immediately after your blood draw. Contact your
healthcare worker if you feel pain or see redness, swelling, or discharge from the puncture
site.
What are the risks?
Blood: During a blood draw, a hematoma (blood-filled bump under the skin) or slight
bleeding from the puncture site may occur. After a blood draw, a bruise or infection may
occur at the puncture site. The person doing this test may need to perform it more than
once. Talk to your healthcare worker if you have any concerns about the risks of this test.
What are normal results for this test?
Laboratory test results may vary depending on your age, gender, health history, the method
used for the test, and many other factors. If your results are different from the results
suggested below, this may not mean that you have a disease. Contact your healthcare
worker if you have any questions. The following are considered to be normal results for this
test:

Adults: 30 units/L-120 units/L (0.5 nkat/L to 2 nkat/L) [3]

Children: < 350 units/L [4]

Adolescent (male): < 500 units/L [4]

Adolescent (female > 15 years): 25 units/L-100 units/L [4]

What follow up should I do after this test?

Ask your healthcare worker how you will be informed of the test results. You may be asked
to call for results, schedule an appointment to discuss results, or notified of results by mail.
Follow up care varies depending on many factors related to your test. Sometimes there is no
follow up after you have been notified of test results. At other times follow up may be
suggested or necessary. Some examples of follow up care include changes to medication or

treatment plans, referral to a specialist, more or less frequent monitoring, and additional
tests or procedures. Talk with your healthcare worker about any concerns or questions you
have regarding follow up care or instructions.

Phosphorus blood test

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The phosphorus blood test measures the amount of phosphate in the blood.
How the Test is Performed
A blood sample is needed.
How to Prepare for the Test
Your doctor may tell you to temporarily stop taking medicines that may affect the test. These medicines
include water pills (diuretics), antacids, and laxatives.
Do not stop taking any medicine before talking to your doctor.
How the Test will Feel
When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or
stinging. Afterward, there may be some throbbing or slight bruising. These soon go away.
Why the Test is Performed
Phosphorus is a mineral the body needs to build strong bones and teeth. It is important for nerve
signaling and muscle contraction.
This test is ordered to see how much phosphorus is in your blood. Kidney, liver, and certain bone
diseases can cause abnormal phosphorus levels.
Normal Results
Normal values range from 2.4 - 4.1 milligrams per deciliter (mg/dL).
Normal value ranges may vary slightly among different laboratories. Some labs use different
measurements or test different samples. Talk to your doctor about the meaning of your specific test
results.
What Abnormal Results Mean

Higher than normal levels (hyperphosphatemia) may be due to many different health conditions. Common
causes include:

Diabetic ketoacidosis

Hypoparathyroidism

Kidney failure

Liver disease

Too much vitamin D

Too much phosphate in your diet

Use of certain medications such as phosphate-containing laxatives

Lower than normal levels (hypophosphatemia) may be due to:

Alcoholism

Hypercalcemia

Hyperparathyroidism

Too little dietary intake of phosphate

Very poor nutrition

Too little vitamin D, resulting in rickets (childhood) or osteomalacia (adult)

Risks
Veins and arteries vary in size from one patient to another and from one side of the body to the other.
Obtaining a blood sample from some people may be more difficult than from others.
Other risks with having blood drawn are slight but may include:

Excessive bleeding

Fainting or feeling lightheaded

Hematoma (blood accumulating under the skin)

Infection (a slight risk any time the skin is broken)