# Round 1 Test Plan (v4 -- 2026-04-10, taking ALL tests tomorrow at Biomed)

Context: 51M, declining ferritin 93->35, persistent bloating post-alcohol re-exposure (2 wks abstinent), elevated Lp(a) ~800, Atorvastatin 20mg, diverticular disease with Aug 2025 bleeding history.

## CLINICAL CONTEXT FOR THIS REVISION

**April 7, 2026 pain incident:** Sudden intense abdominal pain with nausea, dizziness, heavy sweating, and left arm cramping/vibration sensation. Peaked at 15-20 min duration, resolved in ~5-10 min. Worst pain event ever. No blood in stool during episode. Alchohol re-exposure for 1-2 months suspected trigger. Gut noticeably worse than before this drinking period. Still get extreme postprandial bloating. Spot pains at bottom of abdomen both sides. Appetite reduced (takes longer to feel hungry between meals). Stool consistency remains good (toothpaste firmness).

**April 9, 2026 daily observation:** Half tuna egg baguette alone = hardly any bloating. Same meal + freshly squeezed orange juice = very bloated (suspects juice as trigger). Stomach "like someone pregnant" after meals. Reports tired and mental fog -- suspects iron levels may be very low.

**Decision:** Taking all panels A+B+C at once tomorrow at Biomed. No panel groupings. Stool samples deferred to Round 2.

**Research basis:** Cross-referenced with gastroenterologist standard workup guidelines for chronic bloating + abdominal pain + bleeding history. Biomed test catalog browser-scraped (530 tests) to confirm availability and pricing.

## ROUND 1: Blood Tests at Biomed

All tests below ordered together at Biomed. Total: ~$148.

| Test | Biomed Name | Price | Why |
|------|-------------|-------|-----|
| CBC | CBC/Hg | $2.50 | Hb trend, MCV, RDW for iron deficiency. Last Hb 13.1 (Dec). Platelets 439 (persistent thrombocytosis) |
| Ferritin | Ferritin | $7.50 | Dec: 35.3. Trend 93->55->35 over 4 months. If <30 now, confirms true iron loss. April 9: reports tired + mental fog, suspects iron very low |
| CRP hs | CRP (hs) | $1.75 | Inflammation baseline. Dec: 2.86. If >5, suggests active process |
| Total IgA | IgA | $10.00 | Immunoglobulin A screen. Baseline immune status. Paired with tTG IgA (not at Biomed -- see below) for celiac rule-out |
| AST+ALT | SGOT + SGPT | $1.50 | Liver stress. Dec AST:ALT 18:19 = 0.95 (normal, no alcohol pattern) |
| GGT | GGT | $1.25 | Alcohol recovery marker. Dec: 22 (normal), but recent re-exposure |
| Bilirubin | Bilirubin T,D&I | $2.00 | Liver function baseline |
| Alk Phosph | Alkaline Phosphatase/PAL | $1.25 | Complete liver picture |
| Lipid Panel | Bilan Lipid | $5.75 | Atorvastatin check. With Lp(a) 800+, target LDL <55 mg/dL per ESC very-high-risk |
| ApoB | Apo Lipoprotein B | $12.50 | Best CVD risk marker alongside Lp(a). Oct: 63.9 (good) |
| Vitamin B12 | Vitamin B12 | $17.50 | Last check Sep 2025 (396). Chronic alcohol depletes. B12 def causes GI symptoms: bloating, discomfort, appetite loss |
| Lipase | Lipase | $6.00 | April pain episode needs pancreatic rule-out. Sudden severe upper abdominal pain with nausea fits pancreatic pattern. Dec: 35.3 (normal) |
| Amylase | Amylase/Blood | $1.50 | Companion to lipase for pancreatic assessment. Dec: 35.3 (normal) |
| Vitamin D | Vitamin D Total | $30.00 | Supplementation gaps since Oct 2025. Was 98.7 nmol/L (Nov). Affects inflammation and immune function |
| TSH | TSH ultra sensitive | $7.00 | Thyroid screen. Bloating + fatigue overlap with hypothyroidism. Dec: 3.61 (upper-normal, rising trend 2.0->2.65->2.82->3.61) |
| PSA | PSA Total | $10.00 | Trending: 1.3 -> 1.5 -> 2.0 (ref 0-2.5). Approaching upper limit |
| Gastrin | Gastrin | $19.50 | Rules out hypergastrinemia/Zollinger-Ellison as bloating cause. Rarely first-line but Biomed has it |
| ESR | ESR | $1.00 | $1. Cheap complement to CRP. Dec: 22 (slightly elevated, ref <20). Shows chronic inflammation pattern |
| TIBC | TIBC | $7.75 | Iron-binding capacity. Dec: 56.1 (ref 49-83, normal). With falling ferritin, shows whether iron depletion is progressing vs. stable. Paired with ferritin to distinguish true depletion from inflammation artifact |
| ABO Blood group & Rh | ABO Blood group and Rhesus | $2.00 | Blood type + Rhesus factor. 1 day. Uses same EDTA draw as CBC |
| Magnesium | Magnesium | $1.50 | Alcohol depletes Mg. Dec: 0.82 (ref 0.71-0.94, normal mid-range). Cheap completeness, relevant given cramping symptom and alcohol history |

**Total at Biomed: ~$149.75**

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## Tests Biomed Does NOT Provide (get separately for Round 1)

The following tests are clinically relevant but NOT available at Biomed. Arrange separately:

- **tTG IgA (Celiac screen)** -- Not at Biomed. Was negative Dec 2015 but celiac develops in adulthood. Ask gastro specialist if RPH or another Phnom Penh lab offers it.
- **Resting ECG** -- Not at Biomed. Given April 7 episode (dizziness, sweating, left arm cramping/vibration + Lp(a) 800+), a baseline ECG is warranted. Get at Royal Phnom Penh Hospital or a local walk-in clinic. Minimal cost, 10-minute procedure. Screen for Q waves (prior silent MI), LVH, conduction abnormalities, ischemic changes.

---

## Excluded (with reasons)

| Test | Price | Why |
|------|-------|-----|
| hs-Troponin T | $15 | Only useful within hours of acute pain. April episode was weeks ago. Reserve for acute recurrence. |
| Serum Iron (Fer serique) | $1.50 | Fluctuates with diet/timing. Only useful with TIBC. TIBC + ferritin + CBC (MCV, RDW) tell the iron story better. |
| ApoA-1 | $12.50 | Redundant with ApoB + lipid panel. |
| Lp(a) repeat | $20 | Genetically determined (~800). Doesn't change. |
| CDT | -- | Unavailable at Biomed. GGT+AST/ALT sufficient for alcohol assessment. |
| D-dimer | -- | No evidence for asymptomatic Lp(a) thrombotic screening. |
| Fecal Elastase | -- | Not available at Biomed. Ask gastro specialist about pancreatic exocrine insufficiency testing locally. |
| SIBO breath test | -- | Not available at Biomed. Ask gastro specialist about SIBO testing in Phnom Penh. |

---

## ROUND 2: Stool Delivery + Result-Triggered Blood Tests

Round 2 happens 3-4 days after Round 1, once all Round 1 results are available. **Logistics:** Pick up stool sample containers at Biomed during your Round 1 visit. Collect samples at home and deliver to Biomed during Round 2. At the same visit, add any blood tests triggered by Round 1 results.

All Round 2 results should be available within a few more days (calprotectin takes 3-5 days total). Take the complete set to the gastro specialist appointment.

### Stool Tests (primary purpose)

| Test | Biomed Name | Price | Why |
|------|-------------|-------|-----|
| **FOB (Fecal Occult Blood)** | Fecal Occult Blood | $7.50 | Detects occult GI bleeding. If positive + ferritin <30 -> likely occult bleeding, discuss with gastro |
| **Fecal Calprotectin** | Calprotectin (fecal) | $65.00 | Current mucosal inflammation snapshot for gastro visit. Last: 87 (from 141, downward trend positive) |
| **H. pylori Antigen (Stool)** | Helicobacter Pylori Antigen | $15.00 | Chronic bloating + iron malabsorption candidate. Last: negative Dec 2025 (0.15) |

**Stool total: $87.50**

### Additional Blood Tests (triggered by Round 1 results, ordered during Round 2 visit)

| Add if Round 1 shows... | Test to Add | Price | Why |
|-------------------------|-------------|-------|-----|
| Ferritin <30, MCV <87, or RDW rising | **CBC + Ferritin** | $10.00 | Confirms iron depletion direction. Paired with FOBT result -> occult bleeding workup |
| CRP >5.0 | **CRP hs + ESR** | $2.75 | Active inflammatory process follow-up. ESR adds chronic inflammation context |
| Lipase >71 but <213 (mildly elevated) | **Lipase + Amylase** | $7.50 | Retest in 3-4 days. If still rising or >213 (3x ULN) -> immediate GI referral |
| LDL >55 mg/dL or ApoB >80 | **Lipid Panel** | $5.75 | Above target for very-high CVD risk with Lp(a) 800+. Discuss Atorvastatin dose increase (currently 20mg) |
| TSH >4.0 or still climbing | **Free T4 + Free T3** | Ask Biomed | Rising trend (2.0->2.65->2.82->3.61) needs full thyroid panel if crossing threshold |
| Ferritin <30 with stable/reduced CRP | Consider **Iron panel** (Serum iron + TIBC repeat) | $9.25 | Sharpens distinction between dietary deficiency vs occult loss |

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## What Results Would Tell You

| Result | Concerning | Reassuring |
|--------|------------|------------|
| CBC + Ferritin | Ferritin <30, MCV dropping, RDW increasing, Hb dropping <13 | Ferritin stabilizes 35-50, normal MCV/RDW, stable Hb |
| AST/ALT + GGT | AST:ALT >2.0, elevated GGT | Normal transaminases, GGT stable at 22 |
| CRP hs | >5.0 mg/L (active inflammation) | Maintaining ~2.86 baseline |
| ApoB | Elevated despite statin = high atherogenic burden compounding Lp(a) risk | At/near 63.9 |
| B12 | <200 pmol/L (deficient, masking iron deficiency on CBC) | >300 pmol/L |
| Lipid panel | LDL >55 mg/dL (above target for very-high CVD risk) | At/near target |
| Lipase | >3x ULN (>213 U/L) = acute pancreatitis | Normal (<71 U/L) |
| TSH | >4.0 mU/L (hypothyroid candidate, continuing upward trend) | Stable around 3.6 or declining |
| TIBC + Ferritin | TIBC rising + ferritin falling = iron depletion progressing | TIBC stable, ferritin flat or rising from 35 |
| Magnesium | <0.71 (deficient) | Stable at 0.82+ |

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## Red Flags Requiring Immediate Action

- FOBT/FIT positive in Round 2
- Hb drops >1.5 g/dL from established 13.1 baseline
- Any visible blood in stool
- Sudden severe chest/epigastric pain with sweating or radiating arm = ER for ECG + hs-Troponin (only during the event)
- Lipase >3x normal = immediate GI referral
- PSA >2.5 (above reference range) -- discuss urology referral