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So…You Don’t Want a Flu Shot

Immunizations are one tool we have to try to keep you healthy. Terrible diseases of the past such as Measles, Mumps, Rubella, Polio, Lockjaw, and others are hardly ever seen anymore due to the success of immunization programs. So we know that immunizations work very well. They are a way to fool your immune system into thinking it is being invaded and have it make the appropriate antibodies to fight off the illness. Then, if you do come into contact with the infection- your body can zap it out before you get sick.

Influenza – or the seasonal flu – really is a bad bug to get. It is not the same as having a cold, although some colds can be very bad and put you in the hospital. The chance of getting very sick and having complications from flu is greater than a regular cold, so it is fortunate we have the yearly flu vaccines to help us out.

If you are looking for a 100% guarantee that the flu shot won’t “bother” you or make you “sick”- we of course cannot guarantee that. The risk of a serious reaction to a flu shot is very small. Some people will develop mild flu-like symptoms such as a low-grade fever, body aches, and soreness at the injection site. The flu vaccine is not a live virus and cannot give you the true flu.

The important thing is that it will decrease your chance of getting the flu and decrease your chance of complications of the flu or ending up in the hospital with dehydration, or pneumonia. The last year of records regarding flu shows that 34,000 people died from the flu and complications in 2018-2019.

Nothing in life is perfect, so yes it is true the flu shot may only protect you from the flu less than 100% of the time. From a betting standpoint, even 50/50 are not that bad odds. This year, with COVID, it is even more important to consider improving your odds to not get the flu, since the symptoms are similar, you may have trouble getting seen for flu symptoms as most medical offices will not let you in unless you have a negative COVID test first.

It is always your choice, you are the boss of your body. But we would urge you to consider re-thinking reasons why you don’t get a flu shot, and maybe this year give it strong consideration.

by Joe Moore, PAC

Cholesterol / Lipid Treatment

If you are seeing us for your cholesterol/ lipids– you need to know we are treating this condition because, like blood pressure, it is a risk factor for having a heart attack or stroke. The 3 biggest risk factors that you can control are smoking, blood pressure, and cholesterol.

The main things we need to know when you come to see us-

Are you taking your medication NOW that we have prescribed? If we sent you a letter with a script or discussed on the phone, it is important to know if you are or are not taking the medication as directed. If not, let us know if it is due to side effects or cost or insurance etc. We can try to make changes that will work with you. Statins are the only med at this time that have proof that they can decrease your risk of heart attack or stroke. Some people have trouble taking statins, they make some people tired, or cause muscle aches. We always recommend trying more than one statin if you have problems. Sometimes, if you have trouble taking a statin, it helps to get more Vitamin D3 and or Co-Q-10 – both can be found in the vitamin section of your pharmacy.

We need to monitor things like your cholesterol level, to see if the med is working, and liver tests and muscle tests to see if the medication is affecting you badly. For most people with multiple medical problems we recommend being checked every 3 months, but some people who are stable we will let come in every 6 months. We do not recommend only checking you once a year when you are on medication.

Lab tests are a little better if you are fasting– but only triglycerides and glucose levels are affected- so if you are here, we will plan on checking labs unless you prefer to come back another day before you eat. If triglycerides or sugar are really high, we may recommend a follow-up visit to recheck them fasting.

There are different guidelines to consider when deciding if you should be on medication. The latest guidelines involve calculating your 10-year cardiovascular risk- if your chance of having a heart attack or stroke is 7.5% or greater, then you should be on a statin. If you have multiple risk factors or strong family history or really high numbers then we will sometimes recommend starting a statin even if risk calculates lower.

Keeping cholesterol low is even more important if you have already had a heart attack or stroke – and there are some newer medications that work very well if the statins do not do the job.

So, keep those follow-ups with us so we can be sure your cholesterol stays under good control and you can have the lowest chance of bad things happening.

Joseph Moore, PAC

Diet and Nutrition: You Are What You Eat

Much has been made in recent months and years about the epidemic of obesity in this country. According to the most current statistics, 127 million adults in America are considered overweight, 60 million adults are considered obese (Body Mass Index, or BMI >30), and 9 million are extremely obese (BMI > 40). That is news that is hardly new to most Americans these days. In fact, it is hard to turn on the news or open the newspaper without hearing facts about how our country is in trouble. Our children are overweight, nobody is getting the proper amount of exercise, and our hectic schedules make eating fast food the only viable option. Yikes!

But all of this begs the question: What can we do to help change things? If a change in our country can begin with one vote, why can’t the obesity epidemic change with one person (then another, then another) making wise and informed food choices? The key is education-and knowing what we eat. .. and what it is helping us to become.

Here are just a few foods to be aware of when you sit down to eat.

1.   Fructose or High fructose corn syrup

Fructose is a simple sugar or carbohydrate, that is found in many foods we eat. It is found naturally in some foods we eat and is also used as a sweetener in many foods as well. Estimates are that about 10% of our modern diet comes from fructose. Fructose in our diet comes from three main sources: sucrose, or common table sugar, high fructose corn syrup (HFCS), and fruit. Though the fruit does contain fructose in conjunction with many other vitamins, the amount of fructose found in fruit is relatively very small compared to the amount of fructose found in many other foods. Consuming fructose in small amounts is not a bad thing. However, consuming too much fructose is when our body begins to have trouble processing it. When the body is overwhelmed it begins processing fructose into glucose (which raise your blood sugar and

HgbA 1 C), and triglycerides (which help to raise your cholesterol) putting you at risk for developing diabetes and heart disease.

Fructose disguises as many things on food labels. Here are some names to watch for that really all mean one thing: FRUCTOSE or SUGAR!

Corn sweetener, corn syrup, dextrose, fruit juice concentrate, lactose, maltodextrin, malt syrup, sucrose, xylose, high fructose corn syrup

Beware of fructose or high fructose corn syrup in the following foods:

Most sodas, many artificially sweetened fruit juices, many breads (even those that state on the package that they are whole wheat), many breakfast cereals, many jams, jellies, syrups, and certain types of ice cream

2.  Trans fats

Trans fats are a special type of synthetically produced fats made when manufacturers add hydrogen to vegetable oil. The problem with trans fats is that since they are synthetically produced, the body cannot use them in the constructive ways-the body simply stores them. Trans fats, like saturated fats, raise LDL cholesterol levels in the blood and put you at increased risk for heart disease.

Cakes, cookies, crackers, pies, bread, margarine (a big culprit! Hint: look for soft-tub margarine-it is less likely to have trans fat), fried potatoes, potato chips, corn chips, popcorn, shortening, salad dressing, some breakfast cereals, candy

3.  Hidden sodium

So you might be saying: I know to watch the amount of fat and sugar I eat. But remember eating foods high in sodium or salt can also be a culprit that is helping undo your diet by raising your blood pressure. And don’t be fooled into thinking that the only source of sodium in your salt shaker. Sodium is found in many foods that many of us eat every day. In fact, 75% of the sodium that we consume is in processed foods­ not salt that we add to our food.

In fact, according to abcnews.com, clinical nutritionist Samantha Heller when she appeared on “Good Morning America,” “The grande Starbucks java chip Frappuccino® light blended coffee has 350 mg of sodium, and one Krispy Kreme chocolate iced cake doughnut has 320 mg. That is about 15% of your daily allowance.” Keep in mind that it doesn’t have to taste salty to contain sodium! Any food with more than 480 mg of sodium should be considered a high-salt food.

Beware of sodium or salt disguises on food labels:   Baking soda, baking powder, MSG, disodium phosphate

Beware of hidden sodium in the following foods:  Canned soup, canned meat, smoked foods, salted nuts, frozen dinners, salad dressings, pretzels, potato chips, cheese, soy sauce, and steak sauce.

The key to proper nutrition and in turn curbing obesity, lowering blood sugar, cholesterol, and blood pressure, and finally preventing diabetes and heart disease, is in knowing what it is we are actually putting into our bodies. Diet and Nutrition: You Are What You Eat!  So read food labels – understanding what they say is extremely important. By being aware of our diet, we actually can become what we eat and be proud.


1.      Obesity in America

2.      Fructose- How worried should we be? From Medscape Journal of Medicine 7/9/08; George Bray, MD

3.      Sugar’s Many Disguises: Recognizing Sugar on Food labels, Laura Dolson; About.com

4.      www.fda.gov

5.      www.abcnews.com


Brittany Rowan, PA-S
Pacific University
School of PA Studies
November 4, 2008

Brittany Rowan, PAS was a Physician Assistant student from Pacific  University PA Program in Oregon. She was with us at Kentwood Square on rotation for her training from August to November 20

Family Medical Care: Osteoporosis Can Be Managed


Osteoporosis is a bone disease that commonly affects older adults; post-menopausal women and elderly men are most often at risk. However, Osteoporosis can be managed. Osteoporosis means that your bones do not have the strength they used to have. This might be from not having enough bone or not enough minerals in your bone. Your bones go through a natural process of being built up and broken down. This process is called ‘remodeling’. However, in osteoporosis, the normal remodeling process is out of balance. This makes your bones weak, fragile, and more likely to break. Osteoporosis can be treated with medications, dietary supplements, and exercise.

Risk Factors

Women are particularly at risk for osteoporosis. Generally, women gain less bone mass than men when they are younger. So, as women age, they have less bone to lose. Also, estrogen – a female hormone tied to bone-building – is lost as women age. Women are more likely to suffer from osteoporosis when estrogen becomes low after menopause.

Certain medications, long-term anticoagulant use, steroids, alcohol, and tobacco can be causes of osteoporosis. So can poor nutrition. Poor nutrition when you are young can lead to osteoporosis when you are older. If you do not build enough bone mass by the time you are 30, you may be at greater risk for osteoporosis. You may also be at risk for osteoporosis if you have low calcium or low vitamin D. Both of these minerals are important for strong, healthy bones.

Family history is important to decide if you are at high risk for osteoporosis. Patients of European or Asian descent are more likely to have osteoporosis than patients from other backgrounds.

Signs & Symptoms

Most often the first sign of osteoporosis is a broken bone. The spine is a common site for fractures. As the bones of the spine become weak from osteoporosis, they lose the ability to hold up to daily stresses. They simply crack under the pressure. The result is often a ‘compression fracture’ and may occur without a fall or other injury. Other sites where fractures commonly occur are the bones of the arms, legs, and hips.

Your health care provider may recommend a bone density scan if you are at risk for osteoporosis. The U.S. Preventative Services Taskforce also recommends screening for bone density in all women at age 65. A bone scan is a simple test that uses a special x-ray machine to measure the quality of your bones. You may hear it called a DEXA scan.

Treatment & Prevention

Osteoporosis can be managed by daily exercise, taking vitamins with vitamin D and calcium, and in some cases a prescription. By now you probably know that exercise is good for you. But regular, weight-bearing exercise is very important for both the treatment and prevention of osteoporosis. Weight-bearing exercise includes walking, strength training, and yoga. If you think you don’t like exercise, do something fun like dancing or playing golf. These are both weight-bearing exercises and don’t feel so much like work. Click for more weight-bearing exercise ideas.

There are several medications used to treat osteoporosis. Fosamax, Boniva, and Actonel have commonly used drugs in a class of medications called bisphosphonates. Typically, these are the first drugs used for both treatment and prevention of osteoporosis. Common side effects from these medications include irritation or ulcers of the esophagus.

A newer treatment for osteoporosis is a drug called Prolia (denosumab). This is given by injection every 6 months. Prolia is an antibody that turns off the body’s mechanism for breaking down bone, helping to restore balanced remodeling. Prolia is used for post-menopausal women who are at high risk for osteoporosis, or for whom other treatments have failed.

Your health care provider may also give you calcium and vitamin D supplements to help strengthen your bones. Continuing good nutrition as you age can help osteoporosis. So can quitting smoking and drinking alcohol.These risk factors are things you can take control of to reduce your chances of osteoporosis.

Next Steps

Talk to your health care provider at Chickahominy Family Practice about your risks for osteoporosis and determine what preventative steps you can take to avoid injury. Be open to changing diet, exercise, and addictive behaviors. With your knowledge about the risks and treatment options for osteoporosis, you and your provider can create a plan that will work best for you.

Dr. Anup Gokli

Prevention & Wellness: Maintaining Your Health

Do my habits really affect my health?
Yes, very much so. All of the major causes of death (such as cancer, heart disease, stroke, lung disease, and injury) can be prevented in part by making healthy lifestyle choices.

Don’t smoke or use tobacco.
Smoking and using tobacco are very dangerous habits. Smoking causes 440,000 deaths in the United States every year. More preventable illnesses (such as emphysema, mouth, throat and lung cancer, and heart disease) are caused by tobacco use than by anything else. The sooner you quit, the better.

Limit how much alcohol you drink.
This means no more than 2 drinks a day for men and 1 drink a day for women. One drink is equal to 1 can of beer (12 ounces), a 4-ounce glass of wine, or a jigger (1 ounce) of liquor. Too much alcohol can damage the liver and contribute to some cancers, such as throat and liver cancer. Alcohol also contributes to deaths from car wrecks, murders, and suicides.

Eat healthy.
A healthy diet has many health benefits. Heart disease, certain cancers, stroke, diabetes, and damage to your arteries can be linked to what you eat. By making healthier food choices, you can also lower your cholesterol and lose weight.

Lose weight if you’re overweight.
Many Americans are overweight. Carrying too much weight increases your risk for high blood pressure, high cholesterol, diabetes, heart disease, stroke, certain cancers, gallbladder disease, and arthritis in the weight-bearing joints (such as the spine, hips, or knees). A high-fiber, low-fat diet and regular exercise can help you lose weight and keep it off.

Exercise can help prevent heart disease, high blood pressure, diabetes, osteoporosis, and depression. It can also help prevent colon cancer, stroke, and back injury. You’ll feel better and keep your weight under control if you exercise regularly. Try to exercise for 30 to 60 minutes, 4 to 6 times a week, but remember that any amount of exercise is better than none.

Don’t sunbathe or use tanning booths.
Sun exposure is linked to skin cancer, which is the most common type of cancer in the United States. It’s best to limit sun exposure and wear protective clothing and hats when you are outside. Sunscreen is also very important. It protects your skin and will help prevent skin cancer. Make sure you use sunscreen year-round on exposed skin (such as your face and hands). Choose a broad-spectrum sunscreen with at least an SPF 15 and one that blocks both UVA and UVB light.

Practice safe sex.
The safest sex is between 2 people who are only having sex with each other and who don’t have a sexually transmitted infection (STI) or share needles to inject drugs. Use latex condoms and a spermicide (a product that kills sperm) gel or cream. Talk with your doctor about being tested year for STIs.

Keep your shots up to date.
Adults need a tetanus-diphtheria booster every 10 years. Your doctor may substitute one Td booster with Tdap, which also protects you against pertussis (whooping cough). If you’re pregnant and have not had a Tdap shot before, you should be vaccinated during the third trimester of your pregnancy or late in the second trimester. Adults and teens who are in close contact with babies younger than 12 months and who have not received a Tdap shot before should get vaccinated as well. Adults should also get a flu shot each year. Ask your doctor if you need other shots or vaccines.

Make time for breast health.
Breast cancer is one of the most common causes of death for women. Between the ages of 50 and 74, women should have a mammogram every 2 years to screen for breast cancer. Women who have risk factors for breast cancer, such as a family history of breast cancer, may need to have mammograms more often or start having them sooner.

Get regular Pap Smears.
Unless your doctor suggests that you need one more often, you should have Pap smears:

  • Every 3 years beginning at 21 years of age and continuing until 65 years of age
  • Within 3 years of when you start having sex if you are younger than 21 years of age
  • If you are between 30 and 65 years of age and you want to have Pap smears less often, talk to your doctor about combining a Pap smear with human papillomavirus (HPV) testing every 5 years

Certain things put you at higher or lower risk for cervical cancer. Your doctor will consider these when recommending how often you should have a Pap smear. If you’re older than 65 years of age, talk with your doctor about how often you need a Pap smear. If you’ve been having Pap smears regularly and they’ve been normal, you may not need to keep having them. If you’ve had a hysterectomy with removal of your cervix, talk with your doctor about how often you need a Pap smear. If you’ve never had a high-grade precancerous lesion or cervical cancer, ask your doctor how often you need a Pap smear.

Ask your doctor about other cancer screenings.
Adults should ask their doctor about being checked for colorectal cancer starting at age 50. Depending on your risk factors and family medical history, your doctor may want to check for other types of cancer.

Should I have a yearly physical?
Health screenings are replacing the yearly physical. Instead of every person getting the same exams and tests, only the appropriate ones are given. Talk to your family doctor about your risk factors and what tests and exams are right for you.Make essential health benefits and preventive care services work for you.

Essential health benefits are a set of health care service categories that must be covered by certain plans, beginning in 2014.If you buy a plan through a Health Insurance Marketplace, your insurance will cover the preventive services and at least 10 essential health benefits required by the Affordable Care Act (ACA). All private health insurance plans offered in federally facilitated marketplaces will offer the following 10 essential health benefits:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as surgery)
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

State-run marketplaces will also be required to offer 10 EHBs, but the list of benefits may differ.A preventive service might be a test, or it might be advice from your doctor. Preventive services can detect disease or help prevent illness or other health problems. Some preventive services covered under the Affordable Care Act (ACA) include blood pressure screening, cervical cancer screening, HIV screening, immunizations, and well-woman visits. Beginning in 2015, the ACA will require every health plan to cover all costs associated with preventive services. View a complete list of preventive services covered by insurance plans that meet ACA requirements.

Other Organizations

  • U.S. Surgeon General’s My Family Health Portrait

by Dr. Anup Gokli

Pediatric Medicine: Blood Test Reference Guide

Doctors,  NPs, and PAs will often order blood tests on a regular basis to monitor your health. The blood chemistry test, also known as the Complete Metabolic Profile (CMP), measures some of the most important chemicals required and produced by your body to function properly.  These include blood chemicals like those produced by the liver, as well as nutritional elements such as vitaminsproteinsfats, and sugar.

A CMP can involve dozens of different tests, but the tests as ordered usually measure many chemicals. We may order only a Basic Metabolic Profile (BMP), which has just electrolytes, sugar, and kidney tests.  A blood count (CBC) measures your blood cells, not chemicals in the blood.  Tests may be ordered individually since some insurances such as Medicare require a specific reason for each test.   Some important tests are discussed below.


Total Protein (TP) – A rough measure of the total amount of serum protein in your body. Protein measurements can reflect not only liver disease, but nutritional state, kidney disease, and many other conditions as well. If the total protein result is abnormal, further tests must be performed to identify which protein fraction, and then which specific protein, is abnormal.

Albumin – The most abundant protein found in Blood plasma, representing 40% to 66% of the total protein in your body. Albumin keeps water inside your Blood vessels. Reduced levels of albumin may reflect a variety of conditions, including primary liver disease, increased breakdown of macromolecules resulting from tissue damage or inflammation, malnutrition, malabsorption syndromes, and renal diseases.

Globulin – Globulins are a diverse group of proteins in the Blood that grouped together represent the second most common proteins (after albumin) in the Bloodstream. Globulin is actually made up of about 60 different important proteins and is one of the components that help to fight infections. Some of the proteins in this group play an important role in Blood clotting. An elevation in the level of serum globulin can indicate the presence of cirrhosis of the liver.

ALT/SGPT (Alanine Aminotransferase) – Found mainly in the liver, the activity of this enzyme is measured in Blood plasma. Damage from alcohol, strenuous exercise, some medications, and a number of diseases can cause high test values. Elevated levels of this enzyme can be an indication of viral hepatitis and other forms of liver disease.

AST/SGOT Aspartate Aminotransferase – An increase of aspartate aminotransferase (AST, formerly referred to as “SGOT”) is found in any condition involving necrosis of hepatocytes, myocardial cells, or skeletal muscle cells. As in AST/SGPT, damage from alcohol, strenuous exercise, some medications, and a number of diseases can cause high test values. Decreased serum AST is of no known clinical significance.

Bilirubin, Total – The coloring agent in the Blood that makes the plasma (serum) part of your Blood yellow. When the bilirubin level is very high for an extended period of time, the whites of your eyes and even your skin may become yellow (jaundice). Bilirubin comes from the breakdown of old red cells in the Blood. Total bilirubin is increased most commonly in liver disease (hepatitis, malignancy, advanced cirrhosis) and due to obstruction of the biliary system (gall stones, pancreatic cancer). Severe hemolytic anemia can cause moderate increases which are almost entirely made up of the unconjugated fraction. Moderate to marked hyperbilirubinemia is seen in some neonates especially if premature and can be caused by inborn errors of bilirubin metabolism or transport in a small number of cases.

Bilirubin, Direct – A specific form of bilirubin (conjugated) that is formed in the liver and excreted in bile. Under normal conditions, very little of this form of bilirubin is found in the Blood. In liver disease, however, this form of bilirubin enters the Bloodstream so that even a slightly high level may indicate a problem with the liver cells, an obstruction of the bile ducts, or impairment of liver cell function.

Alkaline Phosphatase – An enzyme found in all body tissue, but primarily in bones, bile ducts, and in the liver. A high level may indicate bone, liver, or bile duct disease. Some drugs may also cause increased levels. Expected values are higher for those who are growing (children and pregnant women) or when damage to bones or liver has occurred or with a gallstone condition. Low values are probably not significant.

KIDNEY / Electrolytes

BUN (Blood Urea Nitrogen) – A waste product, derived from protein breakdown, produced in the liver and excreted by way of the kidneys. High values may mean that the kidneys are not working as well as they should. BUN is also elevated by Blood loss, dehydration, high protein diets, and/or strenuous exercise which may temporarily and artificially raise levels. A low BUN level may be the result of liver disease, a low protein diet, pregnancy, or drinking an extreme amount of water. Normal BUN levels should be between eight and 23 milligrams per deciliter of blood (mg/dL); normal creatinine levels should be between 0.7 and 1.3 mg/dL.

Creatinine – A waste product largely from muscle metabolism (breakdown). The concentration of creatinine in the blood depends upon the amount of muscle that you have and the ability of your kidneys to excrete creatinine. High values, especially with high BUN levels, may indicate problems with the kidneys. Because of its insensitivity in detecting early renal failure, the creatinine clearance is significantly reduced before any rise in serum creatinine occurs. The renal impairment may be due to intrinsic renal lesions, decreased perfusion of the kidney, or obstruction of the lower urinary tract. Low values are generally not considered significant.

BUN/Creatinine Ratio – By comparing the BUN level in the Blood to the creatinine level, your physician can determine if a high BUN level is caused by kidney disease, dehydration, or gastrointestinal bleeding.

Calcium – Controlled in the Blood by the parathyroid glands and the kidneys, calcium is one of the most important elements in the body. Virtually all of the calcium in your body is found in bone (99%). That other 1% is very important for proper Blood clotting, nerve, and cell and enzyme activity. The parathyroid gland is the main regulator of calcium in the body. An elevated calcium can be due to medication, inherited disorders of calcium handling in the kidneys, bone disease, or excess parathyroid gland activity or vitamin D. Low calcium can be due to malnutrition, drugs, and certain metabolic disorders and should be re-evaluated.

Sodium – An electrolyte regulated by the kidneys and adrenal glands. This element plays an important role in the water/salt balance in your body. There are numerous causes of high and low sodium levels, but the most common causes of low sodium are diuretic usage and excessive water intake in patients with heart or liver disease. A high level can be caused by an excessive intake of salt or even an insufficient intake of water. Sodium levels should be between 136 and 144 millimoles per liter of Blood (mmol/L).

Potassium – Controlled very carefully by the kidneys, potassium is an electrolyte found primarily inside cells. Its role is to maintain water balance inside the cells and to help in the transmission of nerve impulses. It is very important for the proper functioning of the nerves and muscles, particularly the heart. Any value outside the expected range, high or low, requires immediate medical evaluation. This is especially important if you are taking a diuretic (water pill) or heart pill (Digitalis, Lanoxin, etc.) A low potassium level can cause muscle weakness and heart problems. A high potassium level can be found in kidney disease or in the over ingestion of potassium supplements. Potassium levels should be between 3.6 and 5.1 mmol/L.

Chloride – Important to the function of nerves, muscles, and cells. Chloride is an electrolyte regulated by the kidneys and adrenal glands. It is usually associated with a high or low level of sodium or potassium. An increase in serum chloride is seen in dehydration, renal tubular acidosis, acute renal failure, diabetes insipidus, prolonged diarrhea, and some other rare conditions or medications.  Some drugs cause decreased chloride levels. Levels should be between 99 and 108 mmol/L.

CO2– reflects the acid status of your Blood. Abnormally high or low levels may indicate severe problems if you have had prolonged vomiting, are on lots of fluid pills, or if have out-of-control diabetes. Normal values for CO2 in the blood range from 20 to 29 milliequivalents per liter (mEq/L).


Total Cholesterol – Cholesterol in itself is not all bad, in fact, our bodies need a certain amount of this substance to function properly. When the level gets too high, however, serious problems can result. Levels of 200 or more are considered too high for good health. Levels of 240 and above are considered very high risk and may indicate the need for cholesterol-lowering medication. A low-fat diet and regular exercise are recommended. As the level of blood cholesterol increases, so does the possibility of plugging the arteries due to cholesterol plaque build-up. Such a disease process is called “hardening of the arteries” or atherosclerosis. When the arteries feeding the heart become plugged, a heart attack may occur. If the arteries that go to the brain are affected, then the result is a stroke.

HDL Cholesterol – (High-Density Lipoprotein) A ‘good cholesterol’ as it protects against heart disease by helping remove excess cholesterol deposited in the arteries. High levels seem to be associated with a low incidence of coronary heart disease. The latest guidelines recommend an HDL >45.  If your level is below 30, it can signal a significant risk of early heart disease.

Triglycerides – Fat carried in the Blood. Normal triglycerides should be between 50 and 200 mg/dL. Triglyceride levels over 150 mg/dl may be associated with problems other than heart disease. If levels exceed 500 mg/dL, the situation is considered acute. The ways to lower triglycerides are 1) weight reduction, if overweight; 2) reduce animal fats in the diet: eat more fish; 3) take certain medications that your physician can prescribe such as Lopid, Tricor, or Niacin; 4) get regular aerobic exercise; and, 5) decrease alcohol and sugar consumption. Alcohol and sugar are not fats, but the body can convert them into fats, then dump those fats into your Bloodstream. High triglycerides are also associated with pancreatitis.

LDL Cholesterol – (Low-Density Lipoprotein) Considered “bad cholesterol” because cholesterol deposits form in the arteries when LDL levels are high. An LDL level of less than 130 is recommended; 100  is ideal; values greater than 160 are considered high risk and should be followed up by your physician. Those persons who have established coronary or vascular disease or Diabetes may be instructed by their doctor to get their LDL Cholesterol well below 100. You should ask your doctor which LDL target he or she wants for you.

VLDL Cholesterol – (Very Low-Density Lipoprotein) A type of cholesterol found in the blood that is considered to be the most dangerous form of lipoprotein. They carry the least amount of protein and the most amount of fat. They also stick to artery walls and contribute to plaque build-up.

CK/CPK – An enzyme that is very useful for diagnosing diseases of the heart and skeletal muscle. This enzyme is the first to be elevated after a heart attack (three to four hours). If CPK is high in the absence of heart muscle injury, this is a strong indication of skeletal muscle disease. Sometimes this is checked to monitor possible muscle irritation from cholesterol-lowering drugs.

LDH – The enzyme present in all human cells. Anything that damages cells, including blood drawing itself, will raise amounts in the Blood. If Blood is not processed promptly and properly, high levels may occur. If all values except LDH are within expected ranges, it is probably a processing error and does not require further evaluation.

Calcium – Increased levels of plasma calcium may indicate the presence of malignant disease or hyperparathyroidism. Less commonly, it could reflect thyrotoxicosis, vitamin D intoxication, the use of thiazide diuretics, sarcoidosis, and other disorders. Reduced levels of calcium may reflect vitamin D deficiency, renal disease, hypoparathyroidism, magnesium deficiency, and other disorders.

Alkaline Phosphatase (ALP) – Alkaline phosphatases are a family of enzymes that are present throughout the body, but the most important places are in bone, liver, and bile ducts. Elevated levels of ALP are associated with liver and bile duct disorders and bone diseases. Growing children, because of bone growth, normally have higher levels than adults. Low values are not generally considered significant.

Glucose – Glucose is a chief source of energy for all living organisms. Elevated Blood glucose levels (hyperglycemia), in someone who has fasted for 12 hours, maybe an indication of diabetes mellitus if the fasting level is above 124. Lower-than-normal Blood glucose levels (hypoglycemia) may mean too much insulin in your blood, or could be caused in a variety of other ways, often transiently, and must be carefully examined under specific clinical conditions before expanding the diagnosis.

Iron – The body must have iron to make hemoglobin and to help transfer oxygen to the muscles. If the human body is low in iron, all body cells, particularly muscles in adults, do not function properly. Conversely, too much iron can cause injury to the heart, pancreas, joints, and genital parts in both males and females. Excess iron is found in the hereditary Blood disease called hemochromatosis.

Ferritin – Measured to assess the amount of iron, important for red Blood cell production, in the body. Ferritin is useful for the early detection of iron deficiency. Ferritin is the major iron storage protein. The serum ferritin level is directly proportional to the amount of iron stored in the body.

Magnesium – Magnesium, a Blood salt, found primarily inside the cells, helps regulate energy production in the cells and is necessary for nerve function. This test is not often ordered for adults.

Phosphorus – Phosphorus is closely associated with calcium in bone development. Most of the phosphorus in the body is found in the bones. An adequate phosphorus level in the Blood is very important for muscle and nerve function. Increased levels of plasma phosphate ion may indicate imminent renal failure, hypoparathyroidism, acromegaly, excessive phosphate intake, and vitamin D intoxication. Sharply decreased levels of plasma phosphate may reflect starvation or malnutrition, vitamin D deficiency, primary hyperparathyroidism, magnesium deficiency, and diabetic ketoacidosis.


These tests are the most commonly used Blood test tool to measure the number and amount of formed elements in the Blood. Formed elements include red blood cellswhite blood cells, and platelets.

Red Blood Cells (RBC) – Also called erythrocytes, RBCs are responsible for delivering oxygen throughout the body. There are between 3.6 to 6.1 million red Blood cells in a single cubic millimeter of Blood. Anemia, a condition generally defined as a decreased number of red Blood cells, can be caused by certain anti-HIV drugs or be a sign of an underlying illness. Women of child-bearing age may also experience anemia as a result of blood loss from their menstrual periods. One of the most common physical symptoms of anemia is fatigue.

Hemoglobin (HGB) – A protein that enables the RBCs to distribute oxygen throughout the body. A hemoglobin test is done when a person is ill or during a general physical examination. Good health requires an adequate amount of hemoglobin. The amount of oxygen in the body tissues depends on how much hemoglobin is in the red cells. Without enough hemoglobin, the tissues lack oxygen, and the heart and lungs must work harder to try to compensate. If the test indicates a “less than” or “greater than” normal amount of hemoglobin, the cause of the decrease or increase must be discovered. Low hemoglobin usually means the person has anemia. Anemia results from conditions that decrease the number or size of red cells, such as excessive bleeding, a dietary deficiency, destruction of cells because of a transfusion reaction or mechanical heart valve, or an abnormally formed hemoglobin. High hemoglobin may be caused by polycythemia vera, a disease in which too many red Blood cells are made. Hemoglobin levels also help determine if a person needs a Blood transfusion. Normal hemoglobin levels range from 12 to 16 grams per deciliter (g/dL) of Blood. Usually, a person’s hemoglobin must be below eight gm/dl before a transfusion is considered.

Hematocrit – Hematocrit measures the percentage of blood that is occupied by RBCs. Generally speaking, red Blood cells should make up 40% to 52% of the total Blood volume in men and 35% to 46% in women. The hematocrit is a compound measure of red Blood cell number and size.

Calculated Results (Indices) – The values that measure hemoglobin, hematocrit, and platelet components found in red Blood cells. There are five indices:

MCV – (Mean Corpuscular Volume) – Measures the average size of red Blood cells. Range: 80 to 95 femtoliter;
MCH (Mean Corpuscular Hemoglobin) – Reflects the average weight of hemoglobin found in the red Blood cell. Range: 27 to 31 pg/cell;
MCHC (Mean Corpuscular Hemoglobin Concentration) – reflects the average amount of hemoglobin in the red Blood cell. Range: 32 to 36 gm/dl;
MPV (Mean Platelet Volume) – Reflects the average volume of platelets. Range: 7.4 – 10.4 fL; and,
RDW (Red Blood Cell Distribution Width) – Reflects the distribution of the size of the red Blood cell population. Range: 2 to 8% of white Blood cells.


Neutrophils – Neutrophilia (>25,000/µL) brings up the problem of hematologic malignancy (leukemia, myelofibrosis) versus reactive leukocytosis, including “leukemoid reactions.” Laboratory tests of this problem may include an expert review of the peripheral smear, leukocyte alkaline phosphatase, and cytogenetic analysis of peripheral Blood or marrow granulocytes. Neutropenia may be found in certain infections, including typhoid fever, brucellosis, viral illnesses, rickettsioses, and malaria. Other causes include aplastic anemia (see list of drugs above), aleukemic acute leukemias, thyroid disorders, hypopituitarism, cirrhosis, and Chediak-Higashi syndrome.

Lymphocytes – Lymphocytosis is seen in infectious mononucleosis, viral hepatitis, cytomegalovirus infection, other viral infections, pertussis, toxoplasmosis, brucellosis, TB, syphilis, lymphocytic leukemias, and lead, carbon disulfide, tetrachloroethane, and arsenical poisonings. A mature lymphocyte count >7,000/µL in an individual over 50 years of age is highly suggestive of chronic lymphocytic leukemia (CLL). Drugs increasing the lymphocyte count include aminosalicylic acid, griseofulvin, haloperidol, levodopa, niacinamide, phenytoin, and mephenytoin. Lymphopenia is a characteristic indication of AIDS. It is also seen in acute infections, Hodgkin’s Disease, systemic lupus, renal failure, carcinomatosis, and with the administration of corticosteroids, lithium, mechlorethamine, methysergide, niacin, and ionizing irradiation. Of all hematopoietic cells, lymphocytes are the most sensitive to whole-body irradiation, and their count is the first to fall in radiation sickness.

Eosinophils – Eosinophilia is seen in allergic disorders and invasive parasitoses. Other causes include pemphigus, dermatitis herpetiformis, scarlet fever, acute rheumatic fever, various myeloproliferative neoplasms, irradiation, polyarteritis nodosa, rheumatoid arthritis, sarcoidosis, tuberculosis, coccidioidomycosis, smoking, idiopathically as an inherited trait, and in the resolution phase of many acute infections. Eosinopenia is seen in the early phase of acute insults, such as shock, major pyogenic infections, trauma, surgery, etc. Drugs producing eosinopenia include corticosteroids, epinephrine, methysergide, niacin, niacinamide, and procainamide.

Basophils – Basophilia, if absolute and of marked degree, is a great clue to the presence of myeloproliferative disease as opposed to leukemoid reaction. Other causes of basophilia include allergic reactions, chickenpox, ulcerative colitis, myxedema, chronic hemolytic anemias, Hodgkin’s Disease, and status post-splenectomy. Estrogens, antithyroid drugs, and desipramine may also increase basophils.


Platelets are cells in the Blood which are necessary to help Blood clot. A normal platelet count is between 150 to 440 thousand per cubic millimeter. Low platelet counts are called thrombocytopenia which can be caused by some drugs.

Pancreatic Tests – Amylase and Lipase, enzymes produced by the pancreas to aid in the digestion of carbohydrates, are strong indicators of pancreatic disease (pancreatitis) if they are elevated. Pancreatitis, if not properly dealt with, can cause serious nutritional problems and even death. Pancreatitis, diagnosed early, is most often reversible once revealed and treated. Amylase is also found in saliva, and elevated blood levels of amylase are sometimes due to leakage from the salivary glands. Further tests can be done to distinguish between these two sources of amylase.

Serology Tests: Unlike microbiological tests, which look for the presence of a disease-causing microorganism, serologic tests most often look for specific antibodies produced by the immune system in response to specific disease-causing microorganisms. Also unlike microbiology tests, serology tests are very useful to determine if the patient has been exposed to an infection before they begin showing signs of disease.

Syphilis Serology – STS or VDRL – Syphilis is a potentially fatal bacterial infection usually spread via sexual activity (i.e., vaginal, or oral, or anal sex). If detected and treated early, usually during the first year of infection, syphilis can be controlled. If left unchecked, it becomes much more difficult to treat and can result in serious disease of the brain and death. It is generally recommended that those who are sexually active be tested for syphilis antibodies at least annually. Serology testing can also be used to determine if the infection has responded effectively to therapy.

Hepatitis B and Hepatitis C Serology – Hepatitis B virus (HBV) and Hepatitis C virus (HCV) can both cause liver problems. HBV is not usually fatal but can cause liver problems in a small percentage of those infected. HCV, on the other hand, can cause serious liver disease in the majority of patients infected with the virus.

Mononucleosis – Infectious mononucleosis is a viral disease that affects certain Blood cells. It is caused by the Epstein-Barr virus (EBV), which is a member of the herpes virus family.

Epstein Barr –  This test is sometimes checked to see if prolonged fevers or fatigue are caused by this difficult virus.  Antibodies are checked to see if there are signs of recent or past infections.  Most people develop antibodies eventually, but if the early antibodies are present, it may give us a clue to a recent infection causing symptoms.

HIV Antibody Testing – This test has remained one of the least expensive, most reliable methods of diagnosing HIV. HIV antibody testing also allows patients to find out their status many years before they get sick, allowing them to start the medication to treat HIV. Results of this test cannot be given over the phone and you must sign a form explaining the HIV test before we can send it.

OTHER TESTS: There are some tests that do not easily fit into any of the other categories. We group them together here.

Thyroid – There are two often utilized types of thyroid hormones easily measurable in the Blood, thyroxine (T4) and triiodothyronine (T3). For technical reasons, it is easier and less expensive to measure the TSH and that usually tells us what is wrong, if that is off we may also measure FreeT4 level, but T3 is usually not measured on screening tests.

Thyroid Stimulating Hormone (TSH) – This protein hormone is secreted by the pituitary gland and regulates the thyroid gland. A high level suggests your thyroid is underactive, and a low level suggests your thyroid is overactive.  This is usually the test used to screen for high or low thyroid and monitor the dosage of medications such as Synthroid, Levoxyl, Unithroid, etc.

T3 Uptake or Thyroid Uptake – This test often causes confusion. This is NOT a thyroid test, rather a test on the proteins that carry the thyroid around in your bloodstream. Moreover, a high test number may indicate a low level of the protein. The method of reporting varies from lab to lab. The test is to compute the free thyroxine index.

Thyroxine (T4) – This shows the total amount of the T4. High levels may be due to hyperthyroidism, however, technical artifact occurs when estrogen levels are higher from pregnancy, birth control pills, or estrogen replacement therapy. A Free T4 (see below) can avoid this interference.

Free Thyroxine Index (FTI or T7) – A mathematical computation allows the lab to estimate the free thyroxine index from the T4 and T3 Uptake tests. The results tell us how much thyroid hormone is free in the bloodstream to work on the body. Unlike the T4 alone, it is not affected by estrogen levels.

Free T4 – This test directly measures the free T4 in the Blood rather than estimating it like the FTI. It is a more reliable, but a little more expensive test. Some labs now do the Free T4 routinely rather than the Total T4.

Total T3 – This test is usually ordered when thyroid disease is being evaluated. T3 is the stronger and shorter-lived version of thyroid hormone. Some people with high thyroid levels secrete more T3 than T4. In these (overactive) hyperthyroid cases the T4 can be normal, the T3 high, and the TSH low. The Total T3 reports the total amount of T3 in the bloodstream, including T3 bound to carrier proteins plus freely circulating T3.

Free T3 – This test measures the amount of thyroid hormone T3 that is “free” or not bound to carrier proteins.
Blood Sugar / Diabetes tests.

Glucose – This is a measure of the sugar level in your Blood. High values are associated with eating before the test, and diabetes. The normal range for fasting glucose is 60 to125 milligrams per deciliter of blood (mg/dL). According to ADA criteria, diabetes is diagnosed with a fasting plasma glucose of 126 or more. A precursor, Impaired Fasting Glucose (IFG) is defined as the reading of fasting glucose levels of 110 to 125. Sometimes a glucose tolerance test, which involves giving you a sugary drink followed by several Blood glucose tests, is necessary to properly sort out normal from IFG from diabetes.

NOTE: Variations in lab ‘normals’ exist, and Europeans tend to use a ‘two hour after eating’ definition of diabetes rather than fasting glucose. Using the European standard tends to increase the number of people who are classified as having diabetes.

Glycohemoglobin (Hemoglobin A1 or A1c, HbA1c) – Glycohemoglobin measures the amount of glucose chemically attached to your red Blood cells. Since Blood cells live about three months, it tells us your average glucose for the last six to eight weeks. A high level suggests poor diabetes control. Normal HbA1C is below 5 or so, the goal in Diabetes care is to keep it below 7.  If this number is above 8 it is definitely time to change medications or treatment for your sugar.

Fructosamine is a blood test that gives us a look at average blood sugar over a 2 to 3 week period.  It allows us to make changes in medication without waiting the full 3 months before we can test the HbA1C again.  Sometimes this can be done on a machine n the office, other times it is sent to the lab.

Microalbinuria This is a test measured in the urine.  It shows up protein much earlier than the usual urine test done with the dipstick.  If this level is above normal I a diabetic, it is a sign that they should start taking a special medication to protect the kidney, called an ACE Inhibitor or alternately an ARB.  Studies have shown that these medications can prevent some of the kidney damage done by diabetes.

by Dr. Anup Gokli

What You Need to Know About Burns

What causes burns?
You can get burned by heat, fire, radiation, sunlight, electricity, chemicals or hot or boiling water. There are 3 degrees of burns:

First-degree burns are red and painful. They swell a little. They turn white when you press on the skin. The skin over the burn may peel off after 1 or 2 days.

Second-degree burns are thicker burns, are very painful and typically produce blisters on the skin. The skin is very red or splotchy, and may be very swollen.

Third-degree burns cause damage to all layers of the skin. The burned skin looks white or charred. These burns may cause little or no pain because the nerves and tissue in the skin are damaged.

How long does it take for burns to heal?

  • First-degree burns usually heal in 3 to 6 days.
  • Second-degree burns usually heal in 2 to 3 weeks.
  • Third-degree burns usually take a very long time to heal.

How are burns treated?

The treatment depends on what kind of burn you have.  See a doctor if:

  • A first- or second-degree burn covers an area larger than 2 to 3 inches in diameter.
  • The burn is on your face, over a major joint (such as the knee or shoulder), on the hands, feet or genitals.
  • The burn is a third-degree burn, which requires immediate medical attention.

First-degree burn

Soak the burn in cool water for at least 5 minutes. The cool water helps reduce swelling by pulling heat away from the burned skin.  Treat the burn with a skin care product that protects and heals skin, such as aloe vera cream or an antibiotic ointment. You can wrap a dry gauze bandage loosely around the burn. This will protect the area and keep the air off of it.

Take an over-the-counter pain reliever, such as acetaminophen (one brand name: Tylenol), ibuprofen (some brand names: Advil, Motrin) or naproxen (brand name: Aleve), to help with the pain. Ibuprofen and naproxen will also help with swelling.

Second-degree burn

Soak the burn in cool water for 15 minutes. If the burned area is small, put cool, clean, wet cloths on the burn for a few minutes every day. Then put on an antibiotic cream, or other creams or ointments prescribed by your doctor. Cover the burn with a dry nonstick dressing (for example, Telfa) held in place with gauze or tape. Check with your doctor’s office to make sure you are up-to-date on tetanus shots.

Change the dressing every day. First, wash your hands with soap and water. Then gently wash the burn and put antibiotic ointment on it. If the burn area is small, a dressing may not be needed during the day. Check the burn every day for signs of infection, such as increased pain, redness, swelling or pus. If you see any of these signs, see your doctor right away. To prevent infection, avoid breaking any blisters that form.

Burned skin itches as it heals. Keep your fingernails cut short and don’t scratch the burned skin. The burned area will be sensitive to sunlight for up to one year, so you should apply sunscreen to the area when you’re outside.

Third-degree burn

For third-degree burns, go to the hospital right away. Don’t take off any clothing that is stuck to the burn. Don’t soak the burn in water or apply any ointment. If possible, raise the burned area above the level of the heart. You can cover the burn with a cool, wet sterile bandage or clean cloth until you receive medical assistance.

Is there anything I shouldn’t do when treating a burn?

Do not put butter or oil on burns. Do not put ice or ice water directly on second- or third-degree burns. If blisters form over the burn, do not break them. These things can cause more damage to the skin.

What do I need to know about electrical and chemical burns?

A person who has an electrical burn (for example, from a power line) should go to the hospital right away. Electrical burns often cause serious injury to organs inside the body. This injury may not show on the skin.

A chemical burn should be flushed with large amounts of cool water. Take off any clothing or jewelry that has the chemical on it. Don’t put anything on the burned area, such as antibiotic ointment. This might start a chemical reaction that could make the burn worse. You can wrap the burn with dry, sterile gauze or a clean cloth. If you don’t know what to do, call 911 or your local poison control center, or see your doctor right away.

by Dr. Anup Gokli