imaging and laboratory test in medicine
TRANSCRIPT
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Laboratory tests and imaging in medicine
Tomas Koller
Symptoms Clinical sign Clinical diagnosis + =
Diagnosis
Etiological diagnosis
T.K.
Differential diagnosis 1. Differential diagnosis 3. Differential diagnosis 2.
Age Gender Medical and Surgical history
Laboratory tests Medical imaging
Osnova/outline
1. Complete blood count
2. Blood coagulation
3. Serum biochemistry
4. Urine analysis
5. Imaging 1. Chest X ray
2. Abdominal X ray
3. Abdominal ultrasound
4. CT and MRI
5. Endoscopy
1. Complete blood count
• Leucocytes
• Erythrocytes
• Hemoglobin
• Haematocrit
• Mean cellular volume
• Mean hemoglobin conc.
• Platelets
• Reticulocytes
Complete blood cell count Differential white blood cell count
• Neutrofils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
• Absolute count
• Relative count
– % of total leucocytes
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• Leucocytes • Erythrocytes • Hemoglobin • Haematocrit • Mean cellular volume • Mean hemoglobin conc. • Platelets
• 4 – 10.109/l • < Leucopenia
– Decreased production • Bone marrow
– Sequestration • spleen
– Increased consumption • sepsis
• > Leucocytosis – Demarginalisation
• infection
– Increased production • Bone marrow proliferation
Complete blood cell count
• Leucocytes
• Erythrocytes
• Hemoglobin
• Haematocrit
• Mean cellular volume
• Mean hemoglobin conc.
• Platelets
• 4 – 6 . 1012/l
• <anemia
– Descreased production
– Destruction
– Sequestration
• >polyglobulia, polycytemia
– Proliferation
– Hypoxia
Complete blood cell count
• Leucocytes
• Erythrocytes
• Hemoglobin
• Haematocrit
• Mean cellular volume
• Mean hemoglobin conc.
• Platelets
• 120-175 g/l
• Anemia
– Mild <120
– Moderate <100
– Severe <80
• Polycytemia
Complete blood cell count
• Leucocytes
• Erythrocytes
• Hemoglobin
• Haematocrit
• Mean cellular volume
• Mean hemoglobin conc.
• Platelets
• 40-50 %
• >50% polycytemia
• < 40 % anemia
Complete blood cell count
• Leucocytes
• Erythrocytes
• Hemoglobin
• Haematocrit
• Mean cellular volume
• Mean hemoglobin conc.
• Platelets
• 80-100 fl
• Microcytosis < 80 fl – Anemia
– Hemoglobinopathies
• Normocytosis 80-100 fl
• Macrocytosis > 100 fl – Anemia
– Ethanol abuse
– Hyperlipidemia
– Bone marrow dysplasia
Complete blood cell count
• Leucocytes • Erythrocytes • Hemoglobin • Haematocrit • Mean cellular volume • Mean hemoglobin conc. • Platelets
• 150 – 400 . 109/l • Trombocytosis
– Inflammation – Iron deficiency – Proliferation – Splenectomy
• Trombocytopenia – Consumption
• bleeding
– Sequestration • spleen
– Decreased production • Bone marrow disease • Chemotherapy • Radiation
Complete blood cell count
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• Relative count – 0.5-1.5% RBC
• Absolute count – 27-75 . 109/l
• Reticulocytosis – >1.5%
– increased RBC production
– hemolysis
– correction of Fe or vB12 deficit
• Reticulocytopenia – <0.5%
– reduced RBC production
• Leucocytes
• Erythrocytes
• Hemoglobin
• Haematocrit
• Mean cellular volume
• Mean hemoglobin conc.
• Platelets
• Reticulocytes
Complete blood cell count Differential white blood cell count
• Neutrofils • Lymphocytes • Monocytes • Eosinophils • Basophils
• 46-73% • Number of segments (
– Nonsegmented • Younger cells • Shift to left
– Segmented • Older cells • Shift to right
• Neutrophilia > 73% – Bacterial infection – Stress
• Neutropenia – <1 . 109/l neutropenia – <0.5 109/l agranulocystosis
Differential white blood cell count
• Neutrofils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
• 18-44%
• Lymphocytopenia – Bacterial infection
– Proliferation of other clones of cells
– Severe disease
• Lymphocytosis – Viral infection
– Autoimmune dis.
– Clone proliferation • lymphoma
Differential white blood cell count
• Neutrofils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
• 2-12%
• Monocytosis
– Viral infection
Differential white blood cell count
• Neutrofils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
• 0-5%
• Eosinophilia
– Allergic reactions • Atopic disease
• Asthma
• Drug induced allergies
– Parasitic infection
Differential white blood cell count
• Neutrofils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
• 0-1%
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2. Blood coagulation
Blood coagulation
Test Units Normal values
• INR >1.2
– Drugs • Warfarin
– Liver disease
– Consumption • Bleeding
• APTT-R>1.2
– Drugs • Heparin
• LMW heparin
• New anticoagulants
– Liver disease
– Consumption
• Hyper-fibrinogenemia
– Inflammation
– Cancer
– Operation
• Low fibrinogen
– Consumption • Bleeding
• DIC
– Low synthesis • Liver dis.
In practice blood count and coagulation
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3. Serum biochemistry
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• 4.0-5.5 mmol/l
• Hypoglycaemia < 4.0 mmol/l – Fasting – Drug induced – Insulinoma
• Hyperglycaemia >5.6 mmol/l
• Diabetes mellitus – >7.0 mmol/l – 11.1 mmol/l 2 h post 75 g glucose challenge
• Prediabetes
– Impaired fasting glucose 5.6-7.0 mmol/l – Impaired glucose tolerance 7.8-11.1 mmol/l
2 hours post 75 g glucose challenge
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• M 62 – 106, F 44 – 80 umol/l • M 2.8 – 8.0, F 2.0 – 6.7 mmol/l • Low
• Decreased muscle mass
• High • Decreased renal clearance • Dehydration • Renal insufficiency • Renal failure
• Calculated parameters
– Glomerular filtration rate – Normal >1.5 ml/s
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• TP 57-82 g/l, ALB 32-48 g/l • Low
– Low synthesis • Cirrhosis • Malnutrition • Inflammation
– Increased loss • Nephrotic syndrome • Preeclapmsia • Protein loosing enteropathy
• High
– Clonal proliferation – myeloma – Dehydration
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• 34-17.1 umol/l • Total bilirubin
– Conjugated bilirubin – Unconjugated bilirubin
• Hyperbilirubinemia – Unconjugated
• Benign • Haemolysis
– Conjugated • Biliary obstruction • Liver disease with impaired function
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Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• Aspartate amino transferase – M 0.17 – 0.85, F 0.17 – 0.60 ukat/l
• Alanine amino transferase – M 0.20 – 0.80, F 0.20 – 0.60 ukat/l
• Cytolytic enzymes
• Hepatocyte injury
– ALT>AST
• Alcohol – AST>ALT
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• Gamma-glutamyl transpeptidase • Alcaline phosphatase • Cholestatic enzymes • Both high
– Impairement • in bile production or • in bile transport from hepatocytes to intestine
• GGT (M 0.18 – 1.02, F 0.15 – 0.65 ukat/l)
– Inducible enzyme by drugs, alcohol – In steatosis – In cholestasis with ALP
• ALP (M 0.67 – 2.15, F 0.58 – 1.74 ukat/l) – Cholestasis with GGT – Placental ALP – Bone ALP fraction
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• Amylase and lipase – AMS 0-1.67 ukat /l – Lipase 0-1 ukat/l
• Increased in pancreatic damage – Pancreatitis
• AMS > more than 3 times ULN – > 5 ukat/l
• Lipase
– more specific for pancreas
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• Sodium • 132-146 mmol/l • Principle extracellular cation
• Hyponatremia
• Hypernatremia
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• Potassium • 3.5-5.5 mmol/l • Hypokalemia
– Fluid loss • Vomiting • Diarrhea
– Decreased intake • fasting
• Hyperkalemia – Renal failure
Serum biochemistry
• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)
• Calcium total – 2.0-2.75 mmol/l
• Calcium ionized – 1.1-1.35 mmol/l
• Hypocalcemia
• Hypercalcemia
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Protein eletrophoresis
4. Urinalysis
, blood
Urine color
Urinalysis
• Urine biochemistry
Density pH Proteins Bilirubin Hemoglobin Glucose Ketones Urobilinogen Nitrites Leucocytes
Urinalysis
• Urine sediment
Erythrocytes Leucocytes Hyaline casts Other casts
Urinalysis
• Urine proteins
< 0.15 g/24 hours
> 0.5 g/ 24 severely elevated
> 3.5 g / 24 hours – nephrotic proteinuria
• Albuminuria
– Microalbuminuria – mild impairement
– 30-300 mg/liter or mg/24 hours
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Urinary casts
Urinalysis Crystals
5. Imaging
5. Imaging
1. Chest x ray
Normal Chest X ray
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Chest x ray Ribs
Fractured ribs
Chest X ray Angles
Chest X ray The heart
Pericardial effusion Consolidation
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Consolidation
• Density in left lower lung field
• Loss of left heart silhouette
• Diaphragmatic silhouette intact
• No shift of mediastinum
• Blunting of costophrenic angle
Consolidation
• Density in right upper lung field
• Lobar density
• Loss of ascending aorta silhouette
• No shift of mediastinum
• Transverse fissure not significantly shifted
• Air bronchogram
PLEURAL EFFUSION
• Homogenous density
• Meniscus maximum in axilla
• Loss of cardiophrenic angle
• Loss of diaphragmatic and right cardiac silhouette
MASSIVE PLEURAL EFFUSION
• Massive
• Shift of mediastinum
ATELECTASIS RIGHT LUNG
• Homogenous density right hemithorax
• Mediastinal shift to right
• Right hemithorax smaller
• Right heart and diaphragmatic silhouette are not identifiable
LEFT LOWER LOBE ATELECTASIS
• Inhomogeneous cardiac density
• Left hilum pulled down
• Non-visualization of left diaphragm
• Triangular retrocardiac atelectatic LLL
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PLEURAL FIROSIS
• Small right hemithorax
• Diffuse haziness
• Tracheal shift to right
• Blunted costophrenic angle
• Lines not corresponding to fissures
TUBERCULOSIS
• LUL cavities
• RUL infiltrate
• Bilateral upper lobe disease
TUERCULOSIS
• LUL cavity
• Cavity behind clavicle - note increased density of clavicle in the region over lying cavity
• Pleural effusion on right
MILIARY TUBERCULOSIS
• Interstitial nodules
– Uniform size
– Sharper edges
PNEUMOTHORAX
• No vascular markings on right
• No shift of mediastinum to left
• Deep sulcus
• Atelectatic right lung
• Increased haziness on left: Diversion of entire cardiac output
• Small fluid level near costophrenic angle: Hydro pneumothorax
TENSION PNEUMOTHORAX
• No vascular markings on right • Shift of mediastinum to left • Deep sulcus • Atelectatic right lung • Increased haziness on left:
Diversion of entire cardiac output
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PANCOAST TUMOUR
• Right apical mass
• Cavitating mass
• Para tracheal nodes
• 2nd rib destruction
• Calcified nodes (silicosis)
LARGE CELL CANCER
Large Cell Cancer
• Mass RUL
LUNG MASS
Mass
• Round or oval
• Sharp margin
• Homogenous
• No respect for anatomy
• Lung Cancer: Large cell
LUNG ABSCESS
Lung Abscess
• Bilateral
• Multiple
• Fluid level
LUNG ABSCESS
Lung Abscess
• Anterior segment of LUL
• Atypical location for aspiration lung abscess
• Thick wall
• Fluid level
PULMOARY EDEMA
• Bilateral
• Diffuse
• Butterfly pattern
• Soft fluffy lesions
• Coalescing
• Air bronchogram
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EMPHYSEMA
• Hyperinflation
• Hyperlucency
• Low set flat diaphragm
• Vertical heart
• Pre and infra cardiac lungs
• Barrel shape
• Avascular zones
• Cephalization of upper lung fields is not evident
• Predominant basal involvement (not evident)
• 1. Atelectasis
• 2. Pleural effusion
• 3. Pneumonia
• 4. Post-pneumonectomy
Opacified hemithorax
Multiple Lung Nodules
• 1. Metastasis
• 2. Wegener’s granulomatosis
• 3. Rheumatoid nodules
• 4. AVMs
• 5. Septic emboli
Pulmonary Interstitial Edema
• 1. congestive heart failure
• 2. Lymphangitic spread
• 3. Allergic reaction
Congestive heart failure Hilar Adenopathy
• 1. Sarcoidosis
• 2. TB
• 3. Lymphoma
• 4. Bronchogenic ca
• 5. Metastasis
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Dissecting aortic aneurysm
5. Imaging
2. Abdominal x ray
Abdominal X ray
• Plain abdomen
• No preparation
• Standing position
Pneumoperitoneum
Air-fluid levels Small intestinal obstruction
Air in the GI tract
• Meteorism/tympanism
• Some air-fluid levels
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Toxic megaloconon
Renal calculi
5. Imaging
3. Abdominal ultrasound
Adominal ultrasound
• Liver and liver veins
• Gallbladder and bile duct
• Pancreas
• Kidneys
• Spleen
• Aorta, vena cava, iliac vessels
• Urinary bladder
The liver
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Gallbladder and bile duct
Pancreas
Kidney and spleen Aorta
5. Imaging
4. CT scan and MRI
CT scan
Right side Left side
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CT and MRI largely complementary
MRI • Brain (tumors) • Bones • Joints • Muscles • Liver • Small intestine • Vessels • Biliary and pancreatic ducts
– MR cholangio-pancreaticography
• Structural imaging – MRI spectroscopy – MRI elasgography – Diffusion of protons
CT
• Brain (trauma)
• Thyroid
• Lungs and mediastinum
• Abdominal organs
• Acute abdomen
• Colon
• Vessels
• Functional imaging (PET CT) – Small tumors
Magnetic resonance cholangio-pancreaticography (MRCP)
Common bile duct
Main pancreatic duct
5. Imaging
5. Endoscopy
Upper GI endoscopy Gastroscopy
Lesions on the GI mucosa – ulcers, polyps, tumors, inflammation, varices Indications: dysphagia, abdominal pain, hematemesis, melena, anemia, dyspepsia
Lesions of the colon mucosa: polyps, tumors, inflammation Indications: Lower GI bleeding, chronic diarrhea, microcytic anemia, cancer prevention, abdominal pain
Lower GI endoscopy Colonoscopy
Endoscopic retrograde cholangio-pancreaticography
ERCP
Selective cannulation Bile ducts or pancreas
Indications: Therapy only Papilotomy Biliary stone removal Stenting of the biliary or pancreatis stenosis
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Thank you !