Investigations in family doctors practice

doc. Butvyn S.M.

Polyclinical affairs and family doctors departmentMedical faculty

Main methods of instrumental investigations:

Electrocardiography (ECG) Radiology Computed tomography (CT) Magnetic resonance imaging

(MRI) Angiography Radionuclide scanning

Main methods of instrumental investigations:

Ultrasonography (Echo) Endoscopy Biopsy Lung function testing

Electrocardiography

Indicated to electrocardiography

To elucidate cardiac arrhythmias and conduction defects

To diagnose and localise myocardial hypertrophy, ischaemia or infarction

To diagnose electrolyte imbalance and toxicity of certain drugs

Exercise (stress) ECG

By performing an ECG during progressively increasing exercise (usually on a treadmill)

Indication to detect stress-provoked arrhythmias or evidence of ischaemia

Contraindication: unstable angina, decompensated heart failure, severe hypertension

Ambulatory ECG (Holter monitoring)

Continuous recording of one or more ECG leads to a small portable solid state or tape recorder

Indication: detecting transient episodes of arrhythmias or of ischaemia

Radiology Plain chest radiograph Plain abdomen radiograph Barium studies (barium swallow

and meal examination, barium enema)

Plain chest radiograph

To detect lung pathologies (pneumonia, carcinoma, pulmonary tuberculosis, ect.)

To detect heart pathologies (size and shape of the heart, state of the pulmonary blood vessels and lung fields )

Dilatation of individual cardiac chambers

Left atrial dilatation results in prominence of the left atrial appendage, a double cardiac shadow to the right of the sternum and widening of the angle of the carina as the left main bronchus is pushed upward.

Right atrial enlargement projects from the right heart border towards the right lower lung field.

Left ventricular dilatation causes prominence of the left lower heart border and enlargement of the cardiac silhouette. LV hypertrophy does not cause overall cardiac enlargement unless heart failure ensues.

Right ventricular dilatation increases heart size and displaces the apex upward. Differentiation from LV dilatation may be difficult on chest radiograph.

Plain abdomen radiograph

Show the normal soft tissue shadows due to the liver, spleen and kidneys

Gas in the intestine Fluid levels. Areas of opacification due to stones

or to calcification in the liver, pancreas, cysts or blood vessels

Barium swallow and meal examination

Oesophagus - disorder of motility, a filling defect caused by a tumour or varices, a stricture, a diverticulum or a hiatus hernia

Stomach – to detect ulcer, cancers (except infiltrating carcinoma)

Small bowel - to detect structural abnormalities such as diverticula or strictures

Barium enema The colon must be meticulously cleared

of faeces by means of laxatives followed by a cleansing enema just before the barium enema.

Barium alone or, for double-contrast examination, barium and air, is run into the bowel through a self-retaining catheter.

Radiographs are taken with the colonic mucosa coated with barium and the lumen distended with air

Colonic mucosa can be studied in detail and polyps or small tumours identified.

In inflammatory bowel disease mucosal abnormalities are readily recognised.

Endoscopy

Oesophagogastroduodenoscopy (EGDS)

Sigmoidoscope Endoscopic retrograde

cholangiopancreatography (ERCP) Laparoscopy Laryngoscopy Bronchoscopy Mediastinoscopy Cystoscopy

Diagnostic possibilities of the endoscopy

To exam oesophagus, stomach, duodenum, colon, bronchi, larynx, mediastinum, abdomen cavity

To take biopsy To do therapeutic procedures such

as removal of a polyp

Contraindications to endoscopy

Severe hemorrhagia Psychiatry diseases Comas Lung or heart insufficiency of III st. IHD Severe hypertension Severe thyreotoxicosis

Bronchoscopy Detect structural changes, such

as distortion or obstruction To biopsy abnormal tissue in

the bronchial lumen or wall Bronchial brushings, washings

or aspirates can be taken for cytological or bacteriological examination.

Prepare patient to the EGDS and bronchoscopy

The planned EGDS conduct on an empty stomach in the morning.

Local anaesthesia of cavity of mouth and pharynx (greasing of mucus shell by a 3% solution of dicain, rinse of mouth by 0,25% solution of dicain or dispersion from the sprayer of a 3% solution of dicain with addition of 2-3 drops of 0,1% solution of adrenalin.

At a necessity after 15-20 min to research under a skin enter 1 ml 2 % solution of promedol, and 0,5-1 ml 0,1% solution of atropine sulfate

Normal mucosa of oesophagus

Normal mucosa of duodenum

Normal mucosa bulbus of duodenum

Erosive bulbitis

Main types of chronic gastritis (endoscopic):

Superficial gastritisAtrophic gastritisHypertrophic gastritis

Superficial gastritis

Atrophic gastritis

Hypertrophic gastritis

Erosive gastritis

Peptic ulcer in active stage

Peptic ulcer in reparation stage

Peptic ulcer in scary stage

Possible complications of EGDS

perforation of the oesophaguss or stomach whilst passing the instrument or during biopsy

the inhalation of secretions cardiac arrhythmias or arrest transmission of infections

Ultrasound investigation

Prepare patient to the abdominal ultrasonograhy Three days before the inspection to apply

measures for reduction of formation of gas To exclude from a meal the milk, brown bread,

fresh fruits and vegetables, fruit juices To the persons, that suffer by flatulence,

limitation of products, that cause flatulence on two-three days of the use of polyenzyme drugs (festal, digestal, mezym-forte), absorbent carbon is appointed, decoction of chamomile

The inspection is conducted on an empty stomach (necessarily previous starvation about 12 hours)

In the extreme case the research is conducted off the hand.

Gall bladder ultrasound investigation

mostly determine the Gall bladder (GB) on 5-6 sm rihgt from middle line

form rounded or prolate (depending on a cut)

walls GB appear by surrounding fabrics or structure of organ which he is designed on (mostly livers)

the thickness of wall GB does not exceed 3 mm

a cavity of GB is free middle sizes 5-6 x 2-3 sm.

Gall bladder ultrasound investigation (normal)

Echography sings of chronic cholecystitis

Gallstones

Diagnostic values of liver ultrasound investigation

size of liver contours of liver the state of intrahepatic bile ducts presence of focal changes in a liver presence of free liquid in an

abdominal and pleura region the state of intrahepatic vein net

Liver ultrasound investigation (normal)

Echography sings of chronic hepatitis

change of sizes of liver; change of closeness of

liver; possible expansion of portal

vein

Liver ultrasound investigation (chronic hepatitis)

Echography sings of cirrosis of the liver

Diagnostic meaningfulness only at high active and of long duration forms.

heterogeneous increase or reduction of liver

knotted unequal surface heterogeneous ehostructure

Cirrosis of the liver

Secondary malignant tumors in the liver

Ultrasound investigation of the pancreas (normal)

Chronic pancreatitis

Chronic pancreatitis

Diagnostic value of the renal ultrasound

To assess overall renal size and cortical thickness

To distinguish solid tumours from cysts

Excellent screening test for polycystic kidney disease

In investigation of suspected malignant renal tumours ultrasound can give additional information by detecting extension of tumour to renal veins, vena cava, lymph nodes or liver

Diagnostic value of the renal ultrasound

It can demonstrate dilation of the renal pelvis and ureters, which may indicate urinary tract obstruction

To assess residual urine in the bladder after nicturition

Perinephric abscess or haematoma can be demonstrated

Calculi are usually detected but very small stones may be missed

Ultrasound investigation of the kidney (normal)

Double kidney

Transthoracal echocardiography

Diagnostic value of the echocardiography

• to study blood flow• the structure of the

heart • the movement of valves

and cardiac muscle

M-mode echocardiography The EGG is recorded simultaneously and

permits accurate measurements of the timing of cardiac events including the opening and closing of valves. The ultrasound is focused into a narrow beam, and the information is presented graphically with respect to time and depicts the structures through which the beam passes. Characteristic patterns of valve movement are produced in, for example, mitral stenosis, and pericardia effusions arc easily recognized.

Two-dimensional (or cross-sectional) real-time echocardiography

This type of echocardiography is particularly valuable for detecting intracardiac masses, such as thrombi or tumors, or endocarditic vegetations. It is also very useful in defining complex structural abnormalities in congenital heart disease

Transthoracal echocardiography

Transthoracal echocardiography

Doppler cartography

detecting abnormal directions of blood flow, e.g. aortic or mitral reflux

estimating pressure gradients, for example the gradient across a stenosed aortic valve

Computed tomography

Computed tomography

This has virtually taken over from conventional tomography in centres where it is accessible

Diagnostic value of the computed tomography

Lung: determining the position and size of the

pulmonary nodule or mass and whether calcification or cavitation

It was also useful in localising lesions before percutaneous needle biopsy and in assessing the mediastinum and thoracic cage

imaging the mediastinum the new high resolution CT scan is

useful in diagnosing interstitial fibrosis, and in identifying bronchiectasis

CT of the thorax (extensive dilatation of the bronchi -

bronchoectasis)

Diagnostic value of the computed tomography

Abdomen: important technique for defining certain

intraabdominal diseases, particularly those involving inaccessible organs or regions

Thus it is used in the diagnosis and management of pancreatitis and pancreatic cancer

diagnosing diseases of the retroperitoneal space and lymph nodes

assessing the spread of tumour, e.g. gastric cancer, so that decisions can be made on whether surgery should be palliative or curative

Diagnostic value of the computed tomography

Renal diseases: particularly helpful in diagnosis of

masses in the kidney and in perirenal and retroperitoneal tissues

extension of renal tumours to perirenal tissue, retroperitoneal nodes, liver and thorax can be identified

value in assessing the extent of renal trauma, particularly when vascular damage is suspected

demonstrating radioopaque stones

Radionuclide scanning (gastroenterology)

For imaging the liver, spleen and biliary tract.

To assess gastric emptying. In this assessment a radiolabeled meal is eaten, the liquid being labelled with 111mDTPA and the solid with 99mTc-sulphur colloid labelled chicken liver. The test is used particularly to diagnose gastroparesis.

To assess inflammatory bowel disease. A sample of the patient's blood is incubated with 99mTc which is taken up by the neutrophils and macrophages. The labelled cells are also lost into the intestinal lumen through the inflamed mucosa and so the radioactivity in a 48 hour collection of stools gives a measure of the total activity of the disease.

Radionuclide scanning (gastroenterology)

To detect Meckel's diverticulum. 99mTc per-technicate is given and is concentrated in gastric mucosa which is usually present in the diverticulum. It is detected by scanning.

In the detection of gastrointestinal bleeding. The patient's red cells are labelled with 99mTc and are reinjected. Their accumulation at the site of bleeding is detected by scanning over the subsequent 24 hours

Radionuclide scanning (pulmonology)

Ventilation perfusion imaging Its main value is in the detection of

pulmonary thromboemboli. 133Xe gas is inhaled (the ventilation scan) and 99mTc-labelled macroaggregates of albumin, or albumin microspheres, are injected intravenously, the particles becoming trapped in pulmonary microvessels and providing the 'perfusion' scan.

Lung ventilation and perfusion scintigraphy (recent

pulmonary embolism)

Lung scannogramm with J131 (normal)

Lung scannogramm with J131 (cancer of the right lung)

LUNG FUNCTION TESTING

Measurements of ventilatory capacity The forced expiratory volume in one

second (FEV1, forced vital capacity (FVC) and vital capacity (VC) are obtained from maximal forced and relaxed expirations into a recording spirometer and compared with predicted values based on age, sex and height and ethnic group

Abbreviations used in pulmonary function

testing

FEV1 Forced expiratory volume in one second

FVC Forced vital capacity

VC Vital capacity (forced or relaxed)

PEF Peak (maximum) expiratory flow

TLC Total lung capacity

FRC Functional residual capacity

RV Residual volume

LUNG FUNCTION TESTING

Measurements of lung volumes The values are obtained either by

diluting helium (a non-toxic, non-absorbed gas) into the gas in the lungs, or in a whole body plethysmograph.

Normal lung volumes and changes witch occur in

obsructive and restrictive ventilatory defects

LUNG FUNCTION TESTING

Measurements of gas transfer factor The gas transfer factor (diffusing capacity)

may be thought of as the conductance of the lungs for the gas being studied. It forms a useful overall estimate of the ability of the lungs to exchange gases, and is of particular value in interstitial lung disease, sarcoidosis and emphysema. It is normally estimated by measuring the uptake of carbon monoxide from a single breath of a 0.3% mixture in air

LUNG FUNCTION TESTING

Arterial blood gas analysis Modem automatic analysers give a rapid direct

read-out of P02, PC02 and hydrogen ion concentration in arterial blood. Such measurements are of particular value in the management of respiratory failure and asthma and adult respiratory distress syndrome (ARDS).

Ear or pulse oximeters allow continuous non-invasive measurement of arterial oxygen saturation, of value in assessing hypoxaemia and the effects of oxygen therapy

LUNG FUNCTION TESTING

Exercise tests Exercise challenge is a self-evident test for

detecting exercise-induced asthma. Formal exercise tests, in which cardiac and respiratory responses to bicycle or treadmill exercise are measured in the laboratory, are of value in detecting exercise hypoxaemia and in assessing disability due to respiratory disease.

'Everyday' exercise tests, such as measurement of the distance the patient can walk in six minutes, require no complex apparatus and assist in the assessment of disability, handicap and the response to treatment

Sank you for

attention!