2025 update to Inflammation Mastery 4th Edition:
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Laboratory Assessments: General Considerations of Commonly Used Tests
“The laboratory evaluation of patients with rheumatic disease is often informative but rarely definitive.”[5]
Laboratory tests are immensely important in evaluating patients with musculoskeletal pain, as these tests allow the clinician to 1) assess for infection (e.g., subacute osteomyelitis), 2) quantify the degree of inflammation (i.e., with CRP or ESR), 3) assess or exclude other disease processes that may be the cause of pain or dysfunction, and 4) assess for concomitant diseases (e.g., septic arthritis complicating rheumatoid arthritis). Additionally, 5) these tests open the door to more complete patient care and holistic management of the whole person because they allow for a more comprehensive and complete understanding of the patient’s underlying physiology. The recommended routine is to use the following panel of tests when assessing patients with musculoskeletal pain: 1) CBC, 2) CRP, 3) chemistry/metabolic panel, and preferably also 4) ferritin, 5) 25(OH)-vitamin D, and 6) thyroid assessment, minimally including TSH and optimally including free T4, total T3, reverse T3 and anti-thyroid antibodies. The use of a screening evaluation on a routine basis helps identify patients with occult diseases and also allows for more comprehensive management of the patient’s overall health. Other tests are indicated in specific situations. Orthopedicsrelies heavily upon physical examination and imaging, whereas Rheumatology relies more heavily upon laboratory analysis. In Orthopedics, laboratory tests are used mainly for the purposes of discovering or excluding rheumatic and systemic diseases. In Rheumatology, lab tests are used to specifically identify the type of illness, quantify the severity of the condition, and to assess for concomitant illnesses and complications.
Practical checklist of standard and common laboratory tests for the evaluation of complex patients—how to get started: Corralling complexity to liberate cognitive bandwidth for prioritized problem-solving
As clinicians transition from years of experience to decades of expertise and lose their sophomoric naivety, they gain more talent in managing “complex patients”, some of whom present with a complex clinical picture of multiple undiagnosed/mismanaged problems—such as the commonly encountered clinical hologram of multiple endocrine imbalances, multiple nutritional deficiencies, multifocal polydysbiosis[1] and persistent viral activation, including activation of human endogenous retroviruses (HERVs) as discussed in Chapter 4.
Beyond their biomedical problems, complex patients can be dichotomously categorized into those who do/not have significant psychological-psychiatric overlay, either 1) independent from their biomedical problems, such as a patient with a primary mental disorder such as BPD—borderline personality disorder who also has diabetes and autoimmunity, 2) resulting from the biochemistry of their biomedical problems, such as the commonly encountered problem of depression and anxiety resulting from nutritional deficiencies and systemic inflammation, both of which result in hyperglutaminergic neuroinflammation and the resulting disorders in neurotransmission and neuroplasticity, and 3) resulting from the psychosocial impact of their biomedical problems, such the chronically mismanaged patient who has developed secondary hypochondriasis/hypervigilance or depression/anxiety resulting from years of legitimate biomedical problems that have been inadequately diagnosed and undertreated by whatever hodgepodge team of practitioners (commonly more than 20) ranging from energy healers, to internet gurus, to overpaid board-certified specialists. As such, integrative clinicians commonly find themselves juggling a myriad of complex biomedical and psychosocial variables starting from the first clinical encounter, and thus they need to have protocols and heuristics in place to corral the complexity and liberate cognitive bandwidth for prioritized problem-solving.
Practical checklist of standard and common laboratory tests for complex patients—getting started with complex underdiagnosed problems:
Nearly all blood tests are performed in the morning under fasting conditions (eg, no food after the previous dinner, or at least no food after midnight). When possible and practical, generally better to have blood drawn in the mornings of Monday/Tuesday/Wednesday to avoid transportation and processing problems that might occur later in the week/weekend; this is less of a concern in major metropolitan areas in more developed countries such as the USA.
1. Comprehensive metabolic panel:
a. Cystatin C—ordered with any concern about kidney function, including repeated urinary tract infections (UTI) and age over 50y
2. CBC with differential
3. UA—urinalysis:
a. Consider adding a drug screen for patients who might be using recreational drugs
4. Common nutritional/metabolic markers:
a. 25-hydroxy-vitamin D
b. Homocysteine
c. Methylmalonic acid
d. Ferritin—mandatory for initial evaluation and repeated thereafter every few years or as indicated[2]
e. Serum zinc—especially for patients with depression and chronic infections
f. Fasting serum insulin
g. Fasting cholesterol and lipids
h. Serum GSH—glutathione
i. Serum CoQ10—coenzyme Q10
5. Brain markers for neuroinflammation and risk for future problems:
CONFERENCE VIDEO Integrating Functional and Naturopathic Medicine (F.I.N.D.S.E.X.® Protocol) into Medical Practice for Common Primary Care and Specialty Conditions [2020, Moscow]
![CONFERENCE VIDEO Integrating Functional and Naturopathic Medicine (F.I.N.D.S.E.X.® Protocol) into Medical Practice for Common Primary Care and Specialty Conditions [2020, Moscow]](https://substackcdn.com/image/fetch/$s_!Kbmu!,w_280,h_280,c_fill,f_webp,q_auto:good,fl_progressive:steep,g_auto/https%3A%2F%2Fsubstack-video.s3.amazonaws.com%2Fvideo_upload%2Fpost%2F152107091%2Fa8110bd8-2b8c-4b8d-9bbb-fef2cf697b89%2Ftranscoded-00001.png)
This presentation was scheduled to be delivered physically in Moscow in 2020, but obviously the globalists had other plans for us and international travel was canceled during the European lockdown.
Citations to this updated section include:
[1] Vasquez A. Microbiome Dysbiosis: Course Overview, Introduction to Major Concepts. https://inflammationmastery.substack.com/p/microbiome-dysbiosis-1-course-overview
[2] Vasquez A. Musculoskeletal disorders and iron overload disease: comment on the American College of Rheumatology guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. Arthritis Rheum. 1996 Oct;39(10):1767-8. doi: 10.1002/art.1780391027. PMID: 8843875. https://inflammationmastery.substack.com/p/update-to-iron-deficiency-and-iron
[3] Vasquez A. 2-HOUR VIDEO Clinical use of the amino acid acetyl-cysteine, NAC https://inflammationmastery.substack.com/p/2-hour-video-clinical-use-of-the
[4] Vasquez A. 2-HOUR VIDEO Clinical use of the amino acid acetyl-cysteine, NAC https://inflammationmastery.substack.com/p/2-hour-video-clinical-use-of-the
[5] Klippel JH (ed). Primer on the Rheumatic Diseases. 11th Edition. Atlanta: Arthritis Foundation. 1997 page 94
