Download Test 1 CLIs Spring 2013

Common learning
issues
First case block
echocardiography
• Normal findings: normal position, size and movement of
cardiac valves and heart muscle wall, normal directional flow
of blood within heart chambers
• Indications: evaluate heart wall motion (measure of heart wall
function) to detect valvular disease, evaluate the heart during
stress testing and identify and quantify pericardial fluid
• Non-invasive ultrasound to evaluate structure and function of
the heart
• Uses m-mode recordings, 2D and 3D images, Doppler
• M-mode 1D recording of amplitude and rate of motion of
heart structures in real time
echocardiography
• 2D spatial relationships of the heart
• 3D adds images of heart wall and valves
• Color flow doppler: direction and velocity of blood flow within the
heart and great vessels alter ultrasound frequency. Altered direction
and velocity can be coded as shades of colors. Assessing flow across
prosthetic valves and regurgitant or narrow valves
• Diagnose effusion, valvular heart disease, subaortic stenosis,
myocardial wall abnormalities, infarction, aneurysm and cardiac
tumors, ASD and VSD
• Used during exercise stress tests to diagnose areas of hypokinetic
myocardium
• Perflutren (DEFINITY or Optison) opacifying agent enhancing
endocardial borders
• Interfering factors: patients with COPD because of the substantial
amount of air between heart and chest cavity; obese patients space
between heart and transducer is enlarged
Cardiac catheterization
• Normal findings: normal heart muscle motion, normal and
patent coronary arteries, normal great vessels, and normal
intracardiac pressure and volume
• Indications:
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Visualize heart chambers, arteries, and great vessels
Evaluate chest pain
Locate region of occlusion in positive stress test
Determine effects of valvular disease
Right heart measures CO, and PE
catheterization
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Test explanation:
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Catheter passed into heart through peripheral vein or artery (left heart)
Pressures are recorded and radiographic dyes are injected measure CO
Identify locate, and quantify congenital valvular or septal defects
Evaluate severity of acquired defects
Presence and degree of abnormalities such as transposition of great
vessels, patent ductus arteriosus and anomalous venous return to the heart
Evaluate success of previous cardiac surgery or balloon angio
Evaluate cardiac muscle function
Identify and quantify ventricular aneurysms
Locate acquired diseases of the great vessels i.e. atherosclerosis and
aneurysms
Monitor right sided heart pressure and pulmonary wedge pressures,
measure CO
Dilate stenotic coronary arteries, place stent or laser atherectomy
Femoral vein and artery
Blood is sampled for analysis of oxygen content
Dye allows for visualization of heart chambers, valves, and coronary
arteries
Reading frontal chest x-ray
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Designed to look at lungs, not trauma to the ribs etc.
R marker should be on your left side
Glance over the image for any obvious abnormality always look at your four corners
Anterior posterior and posteroanterior
Start at top and make sure trachea is midline
Move to heart, transverse diameter of cardiac silhouette should not be more than 50%
transverse diameter of thoracic cage
Greater the distance between and object and film, the greater the magnification
Right heart convex, left cardiac border at the top should be concave
Left ventricle makes up left heart
SVC makes straight right border
In enlargement left superior border becomes convex
Left enlargement cardiac apex moves down and out
Right enlarges right border is more protuberant
Left and right pulmonary arteries form hilar shadows, left should be more cephalad
Aorta forms knob
Aortopulmonary window between knob and pulmonary artery shadow; should be concave
or suspect mass or adenopathy
Frontal chest X-ray
• Mediastinum shadow is caused by great vessels and vascular
pedicle
• Pedicle extends from thoracic inlet to base of heart; right
border is SVC left is aortic knob
• Divide lungs into horizontal thirds
• Domed diaphragm with right side higher than left
• Lateral costophrenic angles should be sharp and acute
• Look at lower cervical spine and ribs
• Ribs we see are posterior arcs anterior ribs are angled
downward
Lateral radiograph
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Right ventricle is anterior border
Left ventricle is inferior-posterior cardiac border
Left atrium forms superior-posterior cardiac border
IVC can be seen as it enters from abdomen
If left ventricle is 2 cm or more posterior to IVC then it is
enlarged
• Evaluating hila left is posterior to line drawn down from
tracheal air column and one third the size of the right
• Silhouette sign when two objects of similar density are in
direct juxtaposition interface or borders are lost
TSH aka thyrotropin
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Used to diagnose primarily hypothyroidism and to differentiate it from
secondary (pituitary) and tertiary (hypothalamus)
TSH is stimulated by hypothalamic TRH
Low levels of T3 and T4 are underlying stimuli for TRH and TSH
A compensatory elevation of TRH and TSH can occur with primary
hypothyroidism such as surgical or radioactive ablation, burned out thyroiditis,
agenesis, idiopathic, congenital cretinism or antithyroid meds
Function of pituitary or hypothalamus is faulty because of a tumor, trauma, or
infarction so T3 and T4 are low along with TRH and TSH
TSH test monitors exogenous thyroid replacement or suppression
Thyroid replacement goal is to keep TSH in low normal range
Thyroid suppression keeps TSH low used to diminish size of large goiter
Detect primary hypothyroidism in newborns with low T4
Low T4 and normal or elevated TSH is thyroid
Low T4 and low TSH means pituitary
Interfering factors: radioisotope administration, severe illness, diurnal, drugs like
antithyroid, lithium, potassium iodide, and TSH injection
Free thyroxine index
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Evaluate thyroid function
Corrects for changes in thyroid hormone binding serum proteins that can affect
T4
Diagnose hypo and hyperthyroidism
Measures the amount of free thyroxine T4 which is only 1% unbound goes into
cells and is activated
Not affected by TBG abnormalities so it correlates more closely to hormonal
status than total T4 and T3
If TBG is increased the T3 uptake decreases and correcs for increased T4
associated with increased TBG
If TBG is normal and T4 is elevated FT4 will be elevated indicating true
hyperthyroidism
Low FT4 indicates hypothyroidism
Increased levels primary hyperthyroidism, thyroiditis, facticious hyperthyroidism,
struma ovarii
Decreased: hypo, pituitary insufficiency, hypothalamic, iodine insufficiency
Thyroxine total
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Diagnose thyroid function and to monitor replacement and suppressive therapy
Makes up most of what we call thyroid hormone and it is bound to protein
Measured by radioimmunoassay or enzyme linked immunosorbent assay techniques
TSH stimulates thyroid to secrete thyroid hormone high levels of hormone inhibit TRH
Serum test indicates all T4 high levels indicate hyperthyroid, low is hypothyroid
TBG affects results
Interfering factors: increased after iodinated contrast x-ray, pregnancy causes increased
levels, amphetamines, clofibrate, estrogens, heroin, iodinated contrast media, iodine,
methadone, and oral contraceptives increase
Decrease levels: anabolic steroids, androgens, anti-inflammatory drugs, antithyroid drugs,
barbituates, furosemide, nonsteroidal lithium phenytoin, propranolol, propylthiouracil
High: hyper, thyroiditis, dysalbuminemic, hyperthyroxemia, facticious hyperthyroidism,
struma ovarii, TBG increase
Low: hypo, pituitary insufficiency, hypothalamic failure, protein malnutrition and other
protein depleted states, iodine insufficiency, non-thyroid illness
Cardiac stress test
• Normal finding is that patient is able to maintain and obtain
maximal heart rate of 85% for predicted age and gender with no
cardiac symptoms or EKG change
• Evaluate chest pain in a patient with suspected coronary artery
disease
• Determine limits of safe exercise during cardiac rehab or assist
patients with cardiac disease in maintaining good physical fitness
• Detect labile or exercise related hypertension
• Detect intermittent claudication in patients with suspected vascular
occlusive disease in extremeties
• Evaluate effectiveness of treatment in patients taking antianginal or
antiarrhythmics
• Evaluate effectiveness of cardiac intervention
Cardiac stress test
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Provides info about cardiac function
Heart is stressed and then evaluated
Changes indicating ischemia point to coronary occlusion
EKG, HR, and BP are monitored and patient pedals or walks on a treadmill increasing pace
or resistance to stress heart to get heart to target heart rate
Occluded arteries will be unable to meet heart’s increased demand for blood during the
test
Chemical stress testing used when unable to exercise
Dippyridamole causes steal from ischemic areas due to its powerful vasodilation
Dobutamine can also stress the heart
Contraindications: people with unstable angina, patients with severe aortic valvular heart
disease, those who cannot participate in exercise program because of lung or motor
function, patients with MI, patients with severe congestive heart failure
Potential issues: MI, fainting, sever angina, fatal cardiac arrhythmias
Indicates angina, intermittent claudication, abnormal rhythms, coronary artery occlusive
urinalysis
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Normal:
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Appearance: clear
Color: amber yellow
Odor: aromatic
pH 4.6-8
Protein 0-8 mg/dL
Nitrites none
Crystals none
Bilirubin none
Urobilinogen 0.1-1
Casts none
Glucose none
WBC 0-4 low power field
RBC <2
RBC casts none
Specific gravity 1.005-1.030
Leukocyte esterase negative
Ketones none
Ua
• Indications: used as part of routine diagnostic and screening
evaluations can give info on kidneys, performed on essentially
everyone
• Test explanation: divided one is sent to UA the other half is
cultured
• Lab exam:
• Color: clear, cloudy indicates WBC, RBC or bacteria, color
indicates concentration of urine and varies specific gravity,
abnormal color may indicate bleeding from kidney (dark red)
bleeding from lower UT (bright red)
• Dark yellow indicates urobilinogen or bilirubin
• Pseudomonas could cause green urine
UA
• Odor:
• Diabetics have strong, sweet smell of acetone
• UTI causes foul odor
• Fecal odor could be a fistula
• pH
• Alkaline indicates alkalemia, bacteria, UTI or citrus fruits or
vegetables, common after eating
• Acidic urine: dehydration, high meats and cranberries,
• Alkaline causes calcium carbonate, phosphate and magnesium
phosphate stones
UA
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Protein
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Specific gravity
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Indicates if glomerular membrane is intact like in glomerularnephritis, protein
then seeps into urine and can lead to hypoproteinemia which decreases
capillary oncotic pressure causing edema called nephrotic syndrome
Proteinuria indicates renal disease or preeclampsia
Indicates complications of DM, glomerularnephritis, amyloidosis, multiple
myeloma
High indicates concentrated urine
Low is dilute urine
Weight of urine compared to that of pure water
Chronic diseases associated with low specific gravity measure of hydration
status
Dehydration causes it to be really high
Leukocyte esterase
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Positive indicates UTI
UA
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Nitrites
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Ketones
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Poorly controlled diabetes and hyperglycemia, massive fatty acid
catabolism
Bilirubin and urobilinogen
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Screening for UTI, bacteria produce reducase converting nitrates to nitrites
Conjugated bilirubin is water soluble, indicates disease affecting bilirubin
affecting bilirubin metabolism after conjugation or defects in excretion
indicate previously suspected liver disease, gallstones, or drug toxicity
Crystals
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Indicate renal stone formation is imminent
Can be with high serum uric acid levels
Parathyroid causes high phosphate and calcium crystals
UA
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Casts
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Rectangular clumps that form renal distal and collecting tubules, pH must be acidic and urine
concentrated
Hyaline
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Cellular
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Granular
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Conglomerations of degenerated cells
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After exercise and renal disease, result from disintegration of cellular material into granular particles
within a WBC
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Some diseases epithelial cells desquamate into renal tubule fatty droplets become free oval fat bodies or
incorporated into proteins associate with nephrotic syndrome or nephrosis, fatty emboli or bone
fractures
Fatty
Waxy
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Conglomerations of protein, proteinuria
Cell, hyaline, renal failure or further degeneration of granular casts, associated with chronic renal disease
and renal failure or diabetic nephropathy, malignant hypertension, and glomerularnephritis
Epithelial
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Shed from bladder from tumor, infection, or polyps
Tubule epithelial casts indicate glomerulonephritis
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Five or more indicate UTI involving bladder, kidneys, or both
Inflammatory nephritis, glomerulonephritis
pyelonephritis
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Bladder, urethral, and ureteral disease, tumor, trauma stones infection, glomerloneprhitis, renal infarct,
goodpasture, vasculitis, sickle cell, interstitial nephritis, tubular necrosis, pyelonephritis
WBC
RBC
Cardiac cath
• Normal heart muscle motion, normal and patent coronary
arteries, normal great vessels, and normal intracardiac
pressure and volume
• Indications:
• Visualize heart chambers, arteries, and great vessels
• Evaluate chest pain
• Locate region or coronary occlusion in patients with positive
stress test
• Right heart determines CO measures right heart pressures and
can identify pulmonary emboli
cath
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Test explanation:
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Identify, locate, and quantify severity of atherosclerotic, occlusive disease
Evaluate severity of septal defects
Presence and degree of congenital cardiac anomalies
Evaluate previous cardiac surgery
Evaluate muscle function
Identify ventricular aneurysms
Identify and locate acquired disease of great vessels
Evaluate and treat patients with acute MI
Insert a cath monitor right sided heart pressures and pulmonary wedge
pressures
Dilate stenotic coronary arteries place coronary stent or laser arterectomy
In right sided jugular, subclavian, brachial or femoral vein
Left right femoral artery is cannulated or brachial or radial artery
Percutaneous transluminal coronary angioplasty balloon and stent
Arterectomy involves using a rotating knife to breakout plaques
cath
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Contra
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Unable to cooperate
Refuse intervention if an amenable lesion were found
Iodine dye allergy
Pregnant patients
Renal disorders
Bleeding propensity
Complications
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Arrhythmias
Perforation of myocardium
Renal failure
Catheter induced embolic cerebrovascular accident (stroke)
Arterial thrombosis, embolism, or pseudoaneurysm
Infection
Pneumothorax after subclavian insertion
Hypoglycemia or acidosis
Pulmonary function
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Preoperative evaluation of lungs and pulmonary reserve when
planned surgery will cause loss of functional pulmonary tissue like
lobectomy or pneumonectomy risk of pulmonary failure exists or if
preoperative compromised by COPD
Evaluate response to bronchodilator therapy in patients with COPD
Differentiate between restrictive and obstructive forms of chronic
pulmonary disease restrictive (fibrosis, tumors, chest wall trauma)
obstructive (emphysema, bronchitis, asthma)
Determine diffusing capacity of lungs
Perfomance of inhalation tests in patients with inhalation allergies
Pulmonary function
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Test explanation
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Detect abnormalities in respiratory function determine extent of abnormality
Include spirometry, measurement of airflow rates, calculation of lung volumes and
capacities
Spirometer measures air volumes values greater than 80% are normal provides info about
obstruction or restriction
Add a time element plotted on an X-Y axis, maximally inhale then forcefully exhale while
being timed, if diminished a bronchodilator can be given to monitor improvement
Nitrogen and helium techniques monitor lung capacity
Gas exchange measure diffusing capacity of lung using CO abnormal in CHF, pneumonia and
other diseases that fill alveoli with fluid or exudate
Forced vital capacity: amount of air forcefully expelled from maximal inflation
Forced expiratory volume in 1 second (FEV1) in obstructive disease airways are narrowed
and resistance to flow is high therefore not as much air can be expelled in one second and
is less than predicted value restrictive it is decreased because amount of air inhaled is low
in restrictive FEV/FVC is 80% obstructive is a lot less
Maximal midexpiratory flow or force midexpiratory flow maximal rate of airflow through
the pulmonary tree during forced expiration low in obstructive
Pulmonary function
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Maximal volume ventilation maximal volume of air that a patient can breathe in and out during
one minute low in restrictive and obstructive
Tidal volume: volume of air inspired and expired with each normal respiration
Inspiratory reserve volume maximum that can be inspired from end of normal inspiration
Expiratory reserve colume max volume of air that can be exhaled after normal expiration
Residual volume: volume of air remaining of air that can be inspired after normal expiration
Functional residual capacity amount of air left in the lungs after normal expiration
Vital capacity max amount of air that can be expired after max inspiration
Total lung capacity volume to which lungs can be expanded with greatest inspiratory volume
Minute volume volume of air inhaled and exhaled per minute
Dead space part of VT that does not participate in alveolar gas exchange
Forced expiratory flow portion of airflow curve most affected by airway obstruction
Peak inspiratory flow rate flow rate of inspired air during max inspiration indicates large airway
disease
Peak expiratory flow rate max airflow rate during forced expiration
Drug
Clinical app
Adverse affects
Contraindications
Therapeutic
considerations
Atenolol
HTN, angina, thyroid
storm, HF
AV block, bradyarrythmia,
sedation, decreased libido,
mask hypoglycemia,
depression, dyspnea,
wheezing
Bronchial asthma, COPD,
cardiogenic shock,
decompensated heart
failure, 2nd and 3rd degree
AV block, severe sinus
bradycardia
Beta one selective
adrenergic antagonists
ASA
Prophylaxis against
transient ischemic attack,
MI, acute coronary
syndrome, prevent
reocclusion, arthritis, mild
pain or fever
GI bleeding, acute renal
insufficiency,
thrombocytopenia, Reye,
asthma, tinnitus,
dyspepsia, occult bleeding,
prolonged bleeding, rash
NSAID induced sensitivity,
chickenpox of flu like
symptoms, G6PD
deficiency
Bleeding like hemophilia,
von Willebrand
thrombocytopenia
Inhibit Cox 1,2
Use cautiously with GI
bleeds impaired renal
function, vit K deficiency,
purpura, hepatic
impairment
Eptifibatide integrelin
Acute coronary syndrome,
percutaneous coronary
intervention
Major bleeding,
intracerebral hemorrhage,
hypotension, bleeding
History of bleeding, second
GIIb-IIIa, recent major
surgery, recent stroke,
intracranial hemorrhage,
uncontrolled hypertension
Don’t give with second,
minimize arterial and
venous puncture, synthetic
peptide as parenteral
heparin
Prevent embolism,
thrombosis, prevent
systemic embolism with
MI, unstable angina, open
heart surgery, DIC,
maintain patency IV cath
Hemorrhage, heparin
induced
thrombocytopenia,
hypersensitivity, prolonged
clotting time, mucosal
ulceration, hematoma
Heparin induced
thrombocytopenia, active
major bleeding, bleeding
tendencies, open
ulcerative wounds,
conditions that increase
capillary permeability,
severe HTN, bacterial
endocarditis
Unfractionated causes
thrombocytopenia more
than LMW, antihistamines,
cardiac glycosides, nicotine
and tetracycline affect
ability
Cephalosporins, penicillins,
oral anticoagulants,
platelet inhibitors may
increase affects
Don’t use ginger, garlic,
ginkgo
Drug
Clinical app
Adverse effects
Contraindications
Therapeutic considerations
Isosorbide mononitrate
Prophylaxis of angina,
treatment of chronic
ischemic heart disease
Refractory hypotension,
palpitations, tachycardia,
syncope, flushing,
headache
Severe hypotension, shock
or acute MI with low left
ventricular filling pressure,
increased intracranial
pressure, angle closure
glaucoma, co
administration of
phosphodiesterase
inhibitor type V
Preferred due to longer
half life, better absorption,
nonsusceptibility to
extensive first pass, less
rebound angina, greater
efficacy, venous dilation
greater than arterial, can
lead to tolerance
nitroglycerin
Short acting, short term
treatment of acute anginal
attacks
Same as above
Same as above, transdermal
contraindicated in patients
allergic to skin tape, IV
contraindicated in
tamponade, restrictive
cardiomyopathy, constrictive
pericarditis
Same as above, may be less
effected due to shorter half
life
simvastatin
Hypercholesteremia,
familial, coronary
atherosclerosis,
prophylaxis for coronary
atherosclerosis
Myopathy,
rhaddomyolysis,
hepatotoxicity,
dermatomyositis,
abdominal pain,
constipation, diarrhea,
nausea, headache
Active liver disease
pregnancy and lactation
Lowering LDL metabolized by
P450, 3A4 inhibitors increase
risk of myopathy, combo with
bile acid sequestrant or
cholesterol absorption
inhibitor additive decrease in
LDL, combo with niacin
maybe used in high LDL and
low HDL increases risk of
myopathy, gemfibrozil
decreases statin clearance
induce rhabdo
HCTZ/ triamterene
HTN, adjunct in edema
states associated with HF,
cirrhosis, renal dysfunction,
corticosteroid and estrogen
Arrhythmia, stevens-johnson,
pancreatitis, hepatotoxicity,
SLE, hypotension, alkalosis,
vasculitis, photosensitivity,
electrolyte abnormalities,
impotence, restlessness,
blurrred vision, headache,
hyperglycemia, hyperuricemia
Anuria, hypersensitivity to
sulfonamides, co
administration with agents
that prolong QT
First line in treating HTN,
diminish hypercalcuria in
patients at risk for
nephrolithiasis, decreases
glucose tolerance may
unmask diabetes, don’t use
with antiarrhythmic
Ocular exam
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Done without dilating the eye looking at posterior structures of retina
To see peripheral structures like macula you dilate with mydriatic drops
Darken room, turn on light, turn lens to 0 diopter
Shine line over pupil and look for orange/red glow
Opacity of lens is a cataract or detached retina or retinoblastoma
Hippus (spasm) of pupil if you shine light too brightly
Optic disc and retina should be yellowish orange to creamy pink
Vessels become progressively larger as they approach the disc
Minus diopter for nearsighted, positive for farsighted
Look for sharpness or clarity of disc outline, color, size and central physiology, symmetry
Bulging swelled cup caused by increased intracranial pressure called papilledema may be caused
by meningitis, subarachnoid hemorrhage, trauma, and mass lesions
Spontaneous venous pulsations are normal, follow vessels to the periphery notice shape, color,
size, and distribution
Fovea should be a tiny bright light reflection have patient look directly into the light
Look for opacities in vitreous or lens rotating diopters to +10 or 12
Physiologic cup is a small whitish depression from which retinal vessels emerge, grayish spots are
normal
Rings and crescents can be seen as well as medulated nerve fibers (irregular white patches) both
are normal
Serum amylase
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Critical when 3x upper limit (60-120 normal)
Detect and monitor the clinical course of pancreatitis
Ordered frequently when a patient presents with acute abdominal pain
Test explanation
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Most specific for pancreatitis
Amylase is normally secreted from pancreatic acinaar cells into pancreatic duct
and into duodenum
Aids in the digestion of carbs
Damage to acinar or obstruction of duct by carcinoma or gallstones causes
outpouring into intrapancreatic lymph and free peritoneum
Abnormal levels rise within 12 hours of the onset of the disease
It is rapidly excreted to persistence will show if pathology is persistent
Not specific can be elevated for bowel perforation, penetrating peptic ulcer,
duodenal obstruction, salivary gland infection, ectopic pregnancies, severe
diabetic ketoacidosis
Patients with chronic pancreatic necrosis due to tumor or massive hemorrhage
may cause low amylase levels
Serum amylase
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Interfering factors
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Serum lipidemia factitiously decreases amylase
IV dextrse lowers amylase
Aminosalicylic acid, aspirin, azathioprine, corticosteroids, dexamethasone, ethyl
alcohol, glucocorticoids, iodine containing contrast medium, loop diuretics,
methyldopa, narcotic analgesics, oral contraceptives, prednisone
Increased levels
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Acute pancreatitis, chronic relapsing pancreatitis, penetrating peptic ulcer into
the pancreas
GI disease
Acute cholecystitis
Parotiditis (mumps)
Ruptured ectopic pregnancy
Renal failure
Diabetic ketoacidosis
Pulmonary infarction
After endoscopic retrograde pancreatography
Urine amylase
• Normal value up to 5000 somogyi units
• Used to assist in making the diagnosis of pancreatitis although other
nonpancreatic diseases can cause elevated urine amylase levels
• Levels rise later than blood amylase levels
• Several days after the onset of disease serum mmay be normal but
urine levels are significantly elevated, useful for detecting
pancreatitis late in the disease course
• Test explanation:
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Kidneys clear amylase, disorders that affect pancreas cause
increased amylase levels in urine
Serum levels rise transiently after resolution of acute phase of
disease, urine levels remain elevated 5-7 days after onset
Not specific for disorders: parotiditis, cholecystitis, perforated
bowel, peptic ulcer, ectopic pregnancy and renal disease
Tc99 sestamibe
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Measures left ventricular muscle function and coronary artery blood distribution
Tc99 given intravenously then a radiation detector is placed over heart
Myocardial cells take up substance and appear as hotspots on the photoscan where as areas of
ischemia appear as cold spots
First pass gives the best images
A Tc can be given that binds to calcium when ischemia or early infarction has occurred the calcium
leaks out of cardiac cells which shows an MI hotspot scan used when LVH or LBBB is hard to see
on EKG good for those with chest pain 5-10 days before seeing the doctor
Can be used to assess ischemia during stress testing radionuclide injected IV at point of maximal
cardiac stress accumulates in the myocardium in proportion to regional blood flow, normal will
have higher radionuclide activity good for post operative bypass monitoring and the diagnosis of
CAD
Can also evaluate ejection fraction with pertechnate values less than 65% indicates ischemia,
infarction, myopathy
Cardiac flow rapid injection obtaining images immediately to avoid first pass provides info about
direction of flow to and from ventricles good for kids in determining CHD
Computer assisted gated scan allow for myocardial wall photography while in motion showing
myocaytes during cardiac cycle
Drug
Clinical applications
Adverse affects
Contraindications
Therapeutic
considerations
Omeprazole
Peptic ulcer disease,
GERD, erosive
esophagitis, gastic acid
hypersecretion
h. Pylori GI tract
infection
Pancreatitis,
hepatotoxicity,
interstitial nephritis, may
affect effects of
clopidigrel increased risk
of hip, wrist and spine
fracture, hospital
acquired pneumonia,
and enteric infections
including clostridium
difficile, salmonella, E.
coli, headache, rash, GI
discomfort, diarrhea,
anorexia, asthenia, back
pain
hypersensitivity
Proton pump inhibitors
metabolized in liver by
CYP2C19 and CYP3A4
drug interaction with
ketoconazle or
itraconazle due to acid
environment needed to
absorb azole drugs
Aluminum hydroxide
Symptomatic relief of
dyspepsia associated
with peptic ulcer
disease, GERD or hiatal
hernia
Phosphate depletion
(severe weakness,
malaise anorexia),
constipation,
osteomalacia in patients
with renal failure
hypersensitivity
All antacids can
potentially increase or
decrease the rate or
extent of absorption of
concurrently
administered oral drugs
by changing transit time
or by binding the drug
Magnesium hydroxide
Same as above
Diarrhea,
hypermagnesemia in
patients with renal
failure
Hypersensitivity
Same as above
Abdominal pain
GI disorders
Urinary and renal disorders
Abdominal pain acute and chronic
Suprapubic pain
Indigestion, nausea, vomiting including Dysuria, urgency or frequency
blood, loss of appetite, early satiety
Dysphagia and/or odynophagia
Hesitancy, decreased stream in males
Change in bowel function
Polyuria or nocturia
Diarrhea, constipation
hematuria
Jaundice
Kidney or flank pain
Ureteral colic
Urinary incontinence
Abdominal pain
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Visceral pain occurs when hollow abdominal organs like intestines or biliary tree
contract unusually forcefully or are distended or stretched
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Parietal
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solid organs become painful when their capsules are stretched
Pain usually near the midline at levels that vary according to the structure
involved
May be gnawing, burning, cramping or aching
Sweating, pallor, nausea, vomiting, and restlessness
Inflammation in the parietal peritoneum
Steady, aching pain that is usually more severe than visceral
Aggravated by moving or coughing
Referred pain
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Develops as the initial pain becomes more intense and thus seems to radiate or
travel from the initial site
Duodenal or pancreatic refers to the back
Biliary tree to the right shoulder or right posterior chest
Pleurisy or acute MI may appear as epigastric pain
Abdominal pain
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Determine timing, ask where it starts, ask patient to point to pain, ask if it radiates, ask severity
Pay attention to exascerbating or remediating factors: association with meals, alcohol,
medications, stress, body position, use of antacids
Dyspepsia is chronic or recurrent discomfort or pain centered in the upper abdomen
Discomfort is subjective negative feeling that may be bloating, nausea, upper abdominal fullness,
and heartburn
Inflammatory bowel might be related to bloating
Function or nonulcer dyspepsia with 3 month history of nonspecfic abdominal discomfort or
nausea not from an ulcer
Heartburn, acid reflux or regurg more than once a week likely to have GERD related to prolonged
acid clearance damping actions of bicarb, delayed emptying, hiatal hernia
Heartburn is rising retrosternal burning pain or discomfort occurring weekly or more often
associated with chocolate, citrus, coffee, onions, peppermints, alcohol, bending over, exercise,
lifting or lying supine
GERD may cause coughing, wheezing, and aspiration pneumonia or pharyngeal symptoms like
hoarseness and chronic sore throat
“alarm symptoms” difficulty swallowing (dysphagia), pain with swallowing (odyophagia), recurrent
vomiting, GI bleeding, weight loss, anemia are low risk for gastric cancer
BUN
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> 100 mg/dL indicates serious impairment of renal function
Indirect and rough measurement of renal function and GFR
Measurement of liver function
Measures the amount of urea nitrogen in the blood
Formed in the liver as the end product of protein metabolism and digestion
Related to the metabolic function of the liver and excretory function of the
kidney
Elevated BUN is called azotemia
Usually indicates bilateral disease, unilateral can compensate
Shock, dehydration, CHF, and excessive protein catabolism causes increased
levels
GI bleeding can also increase because blood proteins are broken down and
absorbed in the intestines
Ureteral and urethral obstruction can cause postrenal azotemia
BUN
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Synthesis of urea depends on the liver
Decreased BUN indicates liver disease
BUN is taken with creatinine ratio is 6-25
Interfering factors:
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Changes in protein intake, low protein diets decrease BUN
Muscle mass determines BUN
Advanced pregnancy
GI bleeding
Over and underhydration over dilutes BUN
Drugs that increase: allopurinol, aminoglycosides, cephalosporins, chloral
hydrate, cisplatin, furosemide, guanethidine, indomethacin, methotrexate,
methyldopa, nephrotoxic drugs (aspirin, amphotericin B, carbamazepine,
colistin, gentamicin, methicillin, neomycin, penicillin, polymyxin B,
probenecid, vancomysin), propanolol, rifampin, spironolactone,
tetracycline, thiazide and triamterene
Drugs that decrease chloramphenicol and streptomycin
Stool hemoccult
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Screening for colorectal cancer
Test explanation
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Tumors of the intestine grow into the lumen and are subjected to repeat trauma
by the fecal stream
The friable neovascular tumor ulcerates and bleeds
Guaiac chemistry performed on the stool to detect blood peroxidase like activity
of hgb catalyzes reaction of peroxide and a chromogen forming ortholidine
OB can be detected by immunochemical methods called fecal immunochemical
test (FIT) or immunochemical fecal occult blood test not affected by red meats
or plants like Guaiac may fail to recognize upper GI blood
DNA stool sample test is twice as sensitive as guaiac for colorectal precancerous,
benign or malignant tumors because some polyps don’t shed blood
Benign, malignant GI tumors, ulcers, inflammatory bowel disease, arteriovenous
malformations, diverticulosis, hematobilia all cause OB
Hemorrhoids swallowed blood
Stool hemoccult
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Interfering factors
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Bleeding gums following dental procedure or disease
Animal hemoglobin of ingested animal meat
Peroxidase rich vegetables (turnips, horseradish, artichokes, mushrooms, radishes, broccoli,
bean sprouts, cauliflower, oranges, bananas, cantaloupes, grapes)
Anticoags, aspirin, colchicine, iron, nonsteroidal antiarthritics, and steroids
drugs that instigate peroxidation reaction Boric acid, bromides, colchicine, iodine, iron,
rauwolfia
Vitamin C inhibits peroxidation reaction causing false negatives
Results and significance
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GI tumor and polyps
Peptic ulcers
Varices from portal hypertension
IBS
GI trauma or surgery
Hemorrhoids and other anorectal problems
Drug
Clinical
application
Adverse affects
Contraindicatio
ns
Therapeutic
consideration
Donepezil
Mild to
moderate
Alzheimer’s/De
mentia
Diarrhea,
nausea,
vomiting,
cramps,
anorexia, vivid
dreams
Treatment
associated liver
function test
abnormalities
Modest
symptomatic
benefits
ACHe inhibitors
Pantoprazole
Same as
omeprazole
Same as
omeprazole
Same as
omeprazole
Given as IV
decrease acid
secretion by
irreversibly
inhibiting H+/K+
ATPase on
parietal cells
Drug
Applications
Adverse effects
Contraindications
Therapeutic
considerations
Naproxen
Propionic acid,
mild to moderate
pain, fever,
osteoarthritis, RA,
dysmenorrhea,
gout
GI hemorrhage,
ulceration,
perforation,
Stevens-Johnson
syndrome,
pseudoporphyria,
GI disturbance,
tinnitus
GI or intracranial
bleeding, coag
defects, asthma,
urticaria, allergic
type reactions,
significant renal
insufficiency
Longer half life,
20x more potent
causes fewer GI
adverse affects
Ketorolac
Acetic acid
Same as above
Same as above
Analgesia in
postsurgical
patients, used for
no more than 3-5
days
FeSO4
Iron supplement
for anemia due to
blood loss and iron
insufficiency
Stomach upset or
pain, constipation,
diarrhea, nausea
or vomiting
Diabetes, infants,
may upset ulcers,
not to be take with
thalassemias, may
irritate IBS
Alkaline phosphatase
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Used to detect and monitor diseases of the liver or bone
Test explanation
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Highest concentration found in liver, biliary tract epithelium, and bone, intestinal
mucosa and placenta
Functions in alkaline pH
ALP in kupffer cells lining biliary collecting system and is excreted in the bile
Increased in extra and intrahepatic obstructive biliary disease and cirrhosis
Hepatic tumors, hepatotoxic drugs, and hepatitis increase levels
Most sensitive test to detect tumor metastasis to the liver
New bone growth elevates ALP
Osteoblastic metastatic (breast, prostate) tumors
Paget, healing fractures, RA, hyperparathyroidism, and normal growing bones
are sources of elevated ALP
ALP1 is liver origin and is heat stable
ALP2 is inactivated by heat and is bone
ALP 5’ nucleotidase are elevated in diseases of the liver
ALP
• Interfering factors:
• Recent ingestion of a meal can increase levels
• Young children with rapid bone growth
• Albumin made from placental tissue, allopurinol, antibiotics,
azathioprine, colchicine, fluorides, indomethacin, isoniazid,
methotrexate, methyldopa, nicotinic acid, phenothiazine,
probenecid, tetracycline, and verapamil may increase ALP
• Arsencials, cyanides, fluorides, nitrofurantoin, oxalates, and zinc
salts may lower ALP
GGT
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Sensitive to hepatobiliary disease, indicates heavy and chronic alcohol use
Test explanation
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Enzyme participates in the transfer of amino acids and peptides across the cell membrane
Highest concentrations found in liver and biliary tract
Smaller concentrations found in kidney, spleen, heart, intestine, brain, and prostate gland
Detect liver cell dysfunction highly accurate in indicating even slightest degree of
cholestasis
Detects biliary obstruction, cholangitis, or cholecystitis
Parallels elevation of ALP but more sensitive
Not increased in bone disease
Elevated in 75% of patients that chronically drink
Elevated with MI
Interfering factors
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May decrease late in pregnancy
Drugs that increase: alcohol, phenobarbitol, and phenytoin
Drugs that decrease: clofibrate and oral contraceptives
Gliadin antibodies
• Endomysial IgA, gliadin IgA, tissue transglutaminase
• Diagnose celiac disease and sprue by identifying ab to gliadin
and gluten in affected patients
• Crohn, colitis, and severe lactose intolerance may increase
levels
• Test explanation
• Patients cannot tolerate ingestion of gliadin and gluten which
are toxic to intestinal mucosa
• Patients experience severe malabsorptive symptoms
• Gliadin and gluten cause direct mucosal damage and Ig appear
in gut mucosa and in serum
Lactose tolerance test
• Used to diagnose lactose intolerance caused by lactase insufficiency,
intestinal malabsorption, maldigestion, or bacterial overgrowth in
small intestine
• Test explanation:
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Glucose plasma will not rise after the ingestion and the small bowel
is flooded with a high lactose load
Bacterial catabolism occurs in the intestine creates flatus and
hydrogen
Symptoms include flatulence, abdominal cramping, bloating,
diarrhea, and failure to thrive in infants
Lactose load is given and if lactase is absent then the serum glucose
will not rise
Given glucose tolerance test to isolate lack of lactase
Breath test in which expelled air is analyzed for hydrogen content
for when bacteria have taken over small intestine
Lactose tolerance test
• Interfering factors
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Enterogenous steatorrhea (malabsorption)
Strenuous exercise will reduce glucose
Diabetics have high glucose
Smoking may increase blood glucose
Ethnicity
Antibiotics can decrease bacteria and cause false negative
Ptt
• Assess the intrinsic and common pathway of coag
• Evaluates fibrinogen, prothrombin, V, VIII, IX, X, XI, and XII
• Hepatocellular disease prolongs PTT and obstruction which
precludes GI absorption of fat soluble vitamins prolongs time
• Heparin prolongs PTT so it is used for therapy monitoring
• Antihistamines, ascorbic acid, chlorpromazine, heparin and
salicylates prolong PTT
• Early DIC and extensive cancer causes decreased levels
PT and INR
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Evaluate extrinsic and common pathway
Fibrinogen, prothrombin, V, VII, X
Decreased levels: hepatocellular disease affect factors I, II, V, VII, IX, and X
Obstructive biliary disease causes fat malabsorption A, D, E, and K affected
Coumarin ingestion
INR is organized data
Warfarin interferes with vitamin K may be enhanced by aspirin, quinidine, sulfa,
and indomethacin
Barbituates, chloral hydrate and oral contraceptives cause increased coumarin
drug binding decreasing the effects
Alcohol can prolong
Diet high in fat or leafy vegetables may shorten OT
Diarrhea or malabsorption can prolong
Upper GI series
• Visualize esophagus, stomach, and duodenum to evaluate
dysphagia, weight loss, early satiety, upper abdominal pain, ulcer
symptoms or dyspepsia, alcoholism and suspected varices, results of
barium swallow or x-ray shows pathologic condition
• Channels for air, scope, cauterizing tools
• AV malformations, tumors, enteropathies (celiac) and ulcerations
• Video capsule for small intestine and detecting polyps, IBS, ulcers,
tumors of small intestines
• Not for patients who don’t cooperate, severe bleeding, esophageal
diverticula, suspected perf, recent GI surgery
• May cause pulmonary aspiration, perf, bleeding from biopsy,
oversedation, local IV phlebitic reaction, hypotension
sigmoidoscopy
• Direct visualization of rectum and sigmoid colon
• Diagnose suspected pathology of those organs
• Recommended for patients with a change in bowel habits or obvious
occult blood or abdominal pain
• May remove polyps, reduce volvulus, obliterate hemorrhoids
• Could perf colon, bleeding from biopsy sites
• Poor bowel prep may obscure visualization, rectal bleeding may
obstruct lens
• Not for patients with diverticulitis, painful anorectal conditions,
severe bleeding or suspected perf
• Detect colorectal cancer, polyp, ulcerative proctitis,
pseudomembranous colitis, intestinal ischemia
Fecal fat
• Confirm diagnosis of steatorrhea, when patient has large,
greasy, and foul-smelling stools
• Children with CF have obstructed pancreatic ducts so they
cannot be expelled into the intestine
• Any condition that causes malabsorption (sprue, Crohn,
whipple, gallstones, tumor, duct obstructions)
• Short gut causes higher fecal fat
• Enemas and laxatives may increase fat
• Barium and fiber laxatives decrease
• Increased: CF, malabsorption due to celiac, sprue, whipple,
crohn or radiation enteritis, short gut
Barium enema
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Visualize colon, distal small bowel, and appendix indicated when:
abdominal pain, obvious or occult blood in the stools, IBS, suspected
cancer, volvulus ro obstruction
Determines presence of polyps, tumors, and diverticula also anatomic
abnormalities
Assess filling of the appendix failure to fill means appendicitis
Affects diseases of ileum like Crohn, IBS, and fistulas
Air contrast can be sufflated with polyp to increase accuracy
Not to be performed with perf, non cooperative, megacolon
May cause perf, fecal impaction
Residual stool, spasm, and old barium may affect study
Detect: fistula, perf, appendicitis, extrinsic compression of colon from
extracolonic tumor, malrotation, colon volvulus, intussusception, hernia,
colonic stenosis due to ischemia, infection or previous surgery, IBS,
polyps, diverticula, tumor
Lower abdominal pain
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For right lower quadrant ask if the pain is sharp, continuous, intermittent, and
cramping if it migrates to pre-umbilical area it is appendicitis or PID, ruptured
ovarian follicle, ectopic pregnancy
Renal stones cause cramping in left or right lower quad
Left lower quad or diffuse abdominal pain can be associated with fever and loss
of appetite with a mass it may be diverticulitis
Absent bowel sounds and firmness, guarding or rebound indicates small or large
bowel obstruction
Chronic pain ask about diarrhea or constipation
Changes in bowel habits indicate colon cancer without structural abnormalities it
can be IBS
Nausea may progress to retching and vomiting
Retching describes involuntary spasm of stomach, diaphragm, and esophagus
precedes and culminates in vomiting
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Seen in pregnancy, diabetic ketoacidosis, adrenal insufficiency, hyper calcemia,
uremia, liver disease, emotional states, adverse drug reactions
Lower abdominal pain
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Regurgitation occurs in GERD, esophageal stricture and cancer
Vomiting and pain may be small bowel obstruction
Fecal odor occurs with small bowel obstruction or gastrocolic fistula
Make sure vomit doesn’t contain blood brownish or coffee grounds,
blood comes with esophageal or gastric varices, gastritis or peptic ulcer
disease
Lightheaded? Syncope
Anorexia is loss of appetite
Diabetic gastroparesis, anticholingergic meds, gastric outlet obstruction,
gastric cancer, hepatitis cause early satiety
Dysphagia difficulty swallowing orpharyngeal symptoms include
drooling, nasopharyngeal regurg, and coughing
Pointing below sternoclavicluar notch is esophageal dysphagia
Abdominal series
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Anterior posterior “KUB” kidneys, ureter, bladder
Upright radiograph searching for free intraperitoneal air and/or intestinal air-fluid levels
Glance over entire radiograph in relaxed manner allowing for obvious abnormalities to
jump out
Water dense organs like the liver and spleen will pop out presence of bowel gas in right and
left upper quadrant indicate size because they are at lower edges of liver and spleen
A liver shadow to the iliac crest indicates enlargement
Psoas muscles are usually visible
Renal shadows should be visible as gray structures surrounded by black retroperitoneal fat
Look for calcifications in kidneys, ureters, urinary bladder, and gallbladder
Evaluate the bowel gas pattern
Look at bones systematically beginning with ribs and visible spine
Free intraperitoneal air is usually visualized on upright radiograph
Abdominal series
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In adynamic ileus (paralytic ileus or ileus) there is too much bowel gas in the
entire GI tract, may arise from intra-abdominal cases or as a reflex phenomenon
from disease elsewhere
In an obstruction there is usually air-filled, dilated intestine proximal to point of
obstruction and little to no air distal to obstruction
If obstruction versus ileus is unclear you can use a barium series, CT, and
ultrasound
Large bowel obstruction there is dilated colon proximal to obstruction little to
none after
Valvulae conniventes are regularly spaced thin mucosal folds that extend across
the entire small bowel lumen
Somewhat irregularly spaced transverse bands called colon septa or haustral
folds do not extend all the way across colon lumen
Sigmoid volvulus is common in the elderly: chronic constipation results in
redundant sigmoid mesentery that twists on itself causing complete or partial
obstruction showing dramatically dilated sigmoid colon
Abdominal series
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Perforation shows air outside abdominal lumen, AP supine and upright radiographs
Upright allows air to escape to subdiaphragmatic areas
Pneumatosis intestinalis causes air in the wrong place
Gas filled abscesses can be found in abdominal locations
Gut lumen and wall using a GI contrast is cheaper than endoscopy
Upper GI
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Antegrade small bowel
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Use a nasointestinal tube extended to duodenal jejunal junction
Can distend small bowel and stomach and duodenum don’t obstruct visualization
Retrograde small bowel
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Patient drinks additional barium radiographs taken at 15 and 30 min
Enteroclysis
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Patient swallows liquid barium with gas producing crystals
Visualize esophagus, stomach, and small intestine
Use water based medium when perf is suspected
Barium refluxed fro filled colon into the ileum
Must give antispasmodic drugs
Barium enema
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Must have a clean colon give barium via rectal tube
To diagnose ulcers and polyps
Virtual colonoscopy can be done after giving a medication that tags fecal matter
Insufflate the colon with air
For colon cancer discovery
Imaging features of GI
abnormalities
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To detect: intraluminal lesions (polyp, foreign body or exophytic tumor), mucosal lesion
(inflammation), mural lesion ( tumor, transmucosal inflammation and edema  leads to a
napkin ring appearance), extrinsic lesions(large mesenteric nodes adjacent to the gut
displacing gut by external force), extraluminal projections (ulcerations and diverticula)
Heart burn and dysphagia can lead to hiatal hernias common with GERD can be detected on
barium esophagus along with strictures
Esophagography is useful in studying motility disorders
Upper GI series used to detect peptic ulcer diseases seen easily with double contrast
Ulcers appear as blob of increased density filled with barium recurrent deformities of the
adjacent bowel accompany an ulcer
Stomach cancer is ulcerated, irregular mucosal mass
Crohn’s is inflammation with ulcerations and thickening of the bowel, deeper lesions with
skip lesions and deeper ulcerations
Sprue shows small bowel dilation
Ulcerative colitis ulcerations with loss of haustrations
Polyps and cancer can be detected with double contrast barium enema
Imaging features of GI
abnormalities
• Polyposis of the colon is characterized b multiple adenomas all
with malignant potential
• Polyps and tumors detected early with virtual colonoscopy
• Acute appendicitis doesn’t need to be radiographed if physical
exam strongly points to it
• Plain films aren’t really helpful unless calcification is present
• CT can be difficult but will be seen as a small tubular structure
with distended lumen, thickening of the periappendiceal wall
and inflammation of adjacent fat
Signs and symptoms of
hypothyroidism
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Symptoms:
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Fatigue, lethargy
Modest weight gain with anorexia
Dry, coarse skin and cold intolerance
Swelling of face, hands, and legs
Constipation
Weakness, muscle cramps, arthralgias, paresthesia, impaired memory and hearing
Signs:
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Dry, coarse cool skin, sometimes yellowish from carotene, with nonpitting edema and loss
of hair
Periorbital puffiness
Decreased systolic and increased diastolic BP
Bradycardia and in late stages hypothermia
Intensity of heart sounds sometimes decreased
Impaired memory, mixed hearing loss, somnolence, peripheral neuropathy, carpal tunnel
syndrome
Slowed relaxation phase of reflexes such as the ankle reflex
CBC with Diff
• RBC, hgb, HCT, MCH, MCHC, MCV, WBC, neutrophils,
lymphocytes, monocytes, eosinophils, basophils
• Infection
• Anemia
• Indirect coombs is blood antibody screening to determine
type before transfusion
• Add donor serum to recipients blood
• Then do coombs to see if there was a reaction
Coombs test
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Used to detect the patient’s ab coating the transfused RBC evaluating suspected transfusion
reactions
Symptoms of transfusion reaction: fever, chills, rash, flank/back pain, bloody urine, fainting
or dizziness
Methyldopa and levodopa can cause non-blood group antigens to develop on RBC causing
hemolysis
Shows that RBCs have been attacked by ab in the bloodstream
In lymphoma this can develop idiopathically
If RBC have ab on them then coombs serum will cause agglutination greater the quantity
the more clumping
Interfering factors: antiphospholipid ab cause false positive, false positive: ampicillins,
captopril, cephalosporin, chlorpromazine, chlopropamide, hydralazine, indomethacin,
insulin, isoniazid, levodopa, methyldopa, penicillin, phenytoin, procainamide, quinidine,
quinine, rifampin, steptomycin, sulfonamides, and tetracyclines
Indicates hemolytic disease of newborn, incompatible blood transfusion, lymphoma,
autoimmune hemolytic anemia (SLE, RA), mycoplasmal infection, mono, hemolytic anemia
after heart bypass, adult idiopathic hemolytic anemia
Iron, TIBC, and Transferrin
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Evaluate iron metabolism in deficiency, overload, or poisoning
Test explanation
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Serum iron
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Iron deficient anemia: insufficient iron intake, inadequate gut absorption,
increased requirements, loss of blood in menstruation, ulcer, colon neoplasm
Decreased hgb causing microcytic, hypochromic RBC
Decreased MCV and MCHC
Decreased in serum level, elevated TIBC, and low transferrin are anemia
TIBC and transferrin
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Proteins available to bind free iron
During iron overload transferrin stays about the same
In acute inflammatory reactions transferrin lowers also diminished in chronic
illness like malignancy, collagen vascular disease, or liver disease
Hypoproteinemia associated with low transferrin
Increased transferrin in pregnancy and estrogen therapy
TIBC measured by adding excess iron to serum saturating all transferrin, excess
iron is removed iron left is a measurement of TIBC reflective of liver function and
nutrition
IRON, tibc, and transferrin
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Transferrin saturation (serum iron x 100%)/TIBC
Normal level is 20-50%
Below 15% is iron deficient anemia
Increased with hemolytic anemia, sideroblastic, or megaloblastic and iron overload or iron
poisoning
Chronic illness lowers serum iron decreased TIBC normal transferrin saturation
Increased intake or absorption of iron leads to elevated iron levels TIBC is unchanged,
saturation is very high
Interfering factors
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Recent transfusion
High iron meal
Estrogen may increase like chloramphenicol, ethanol, BCP, methyldopa
Decrease: ACTH, cholestyramine, colchicine, chloramphenicol, deferoxamine, methicillin,
testosterone
TIBC increased by fluoride and BCP
TIBC decreased by ACTH and chloramphenicol
Iron test results
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Serum iron increase
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Hemosiderosis, hemochromatosis
Iron poisoning
Hemolytic anemia
Massive blood transfusion
Hepatitis or hepatic necrosis
Lead toxicity
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Serum iron decrease
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Increased TIBC or transferrin
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Malnutrition, hypoproteinemia, inflammatory disease, cirrhosis, hemolytic anemia, pernicious anemia, sickle cell
anemia
Increased saturation
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Estrogen therapy
Pregnancy late
Polycythemia vera
Iron deficient anemia
Decreased TIBC or transferrin
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Insufficient dietary iron, chronic blood loss, inadequate absorption, pregnancy (late), iron deficient anemia, neoplasia
Hemochromatosis or hemosiderosis, increased iron intake, hemolytic anemia
Decreased saturation
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Iron deficient anemia, chronic illness
Drug
Clinical
applications
Adverse
reactions
Contraindication Therapeutic
s
considerations
levothyroxine
T4, for
hypothyroidism,
myxedema coma
Replaces missing
hormone
Hyperthyroidism
, osteopenia,
pseudotumor
cerebri, seizure,
myocardial
infarction
Acute MI,
uncorrected
adrenal cortical
insufficiency
Untreated
thyrotoxicosis
Cholestyramine
and sodium
polystyrene
sulfonate
decrease
absorption of
synthetic thyroid
hormone
Rifampin and
phenytoin
increase
metabolism
T4 desirable
because of its
longer half life