18-Functional examining of the respiratory system; methods X ray, bronchoscopy, respiratory failure etiology, pathogenesis, symptoms; Introduce yourself

lf and explain the procedure. Ensure the patient is comfortable and maintain the patients dignity. Look at the patient from the end of the bed for: general appearance breathing rate pursed lip breathing non-specific signs of illness, interest and interaction with surroundings Then start with the hands: look for (for example) clubbing (Ca bronchus, mesothelioma, bronchiectasis, lung abscess, fibrosing alveolitis, cystic fibrosis, empyema/lung abscess) peripheral cyanosis nicotine staining coarse tremor/flap of CO2 retention (also causes bounding pulse) Look at the face for central cyanosis (lips and tongue) eyes (eg Horners syndrome) Inspect the chest: position patient at 45 degrees, look for respiratory rate use of accessory muscles, wheezing pattern of respiration - Cheyne-Stokes (alternating hyperventilation and apneoa, which occurs in LVF, high altitude and raised intracranial pressure) shape of the chest and scars - asymmetry (in collapse of fibrosis), increased anteroposterior diameter (barrel chest) in COPD Palpation check position of mediastinum by feeling position of trachea between heads of sternomastoid in suprasternal notch apex beat - feel for the furthest point down and out where the pulsation can be felt lymph nodes in supraclavicular fossae Chest Expansion: extend fingers, anchor fingertips laterally around the lower part of the chest so thumbs are 2-4 cm either side of midline but raised up over sternum. Assess extent and symmetry of movement of thumbs apart on inspiration. Percussion: both sides of the chest at top middle and lower segments, including axillae. The finger which is struck should be parallel to the floor. Percuss in the intercostal spaces. Compare sides. increased resonance: means more air and less solid in chest than normal - found in pneumothorax, emphysema decreased resonance: means more solid and less air in chest than normal - found in effusion, solid lung-consolidation, collapse, abscess, neoplasm Auscultation: Use the diaphragm (except above the clavicles, when you use the bell). Listen at the top, middle and bottom of the chest and then in the axillae (comparing like with like on opposite sides). Ask the patient to breathe through their open mouth quite deeply. Breath sounds may be vesicular bronchial (gap between inspiratory and expiratory phases with prolonged expiratory phase) - found in consolidation reduced - in effusion, pneumothorax, collapse, emphysema

Listen for added sounds and note if inspiratory or expiratory: crackles: fine are caused by snapping open of tiny airways (occur in heart failure); medium and coarse - are caused by fluid in larger airways (occur in pneumonia, bronchitis and bronchiectasis) wheezes: mean constricted airways - the higher pitched the wheeze, the greater is the narrowing. pleural rub: pleurisy Vocal Resonance (VR) or Tactile Vocal Fremitus (TVF): Ask the patient to say 99, whilst listening over the chest. Sounds are louder over areas of consolidation. Compare both sides.At the end of the examination ask to see the sputum and measure the peak flow. X-Ray : refer to radiation, waves or particles that travel through the air like light or radio signals. X-ray energy is high enough that some radiation passes through objects (such as internal organs, body tissues, and clothing) and onto x-ray detectors (such as film or a detector linked to a computer monitor). In general, objects that are more dense (such as bones and calcium deposits) absorb more of the radiation from the x-rays and dont allow as much to pass through them. These objects leave a different image on the detector than less dense objects. Specially trained or experienced physicians can read these images to diagnose medical conditions or injuries. Medical x-rays are used in many types of examinations and procedures. Some examples include x-ray radiography (to find orthopedic damage, tumors, pneumonias, foreign objects, etc); mammography (to image the internal structures of breasts) CT (computed tomography) (to produce cross-sectional images of the body) fluoroscopy (to dynamically visualize the body for example to see where to remove plaque from coronary arteries or where to place stents to keep those arteries open) radiation therapy in cancer treatment.
Bronchoscopy: is a test to view the airways and diagnose lung disease. It may also be used during the treatment of some lung conditions.You may have a bronchoscopy to help your doctor diagnose lung problems. Your doctor will be able to inspect the airways or take a biopsy sample. Common reasons to perform a bronchoscopy are: Lung growth, lymph node, atelectasis, or other changes seen on an x-ray or other imaging test Suspected interstitial lung disease Coughing up blood (hemoptysis) Possible foreign object in the airway Cough that has lasted more than 3 months without any other explanation Infections in the lungs and bronchi Inhaled toxic gas or chemical You may also have a bronchoscopy to treat a lung or airway problem, such as: Remove fluid or mucus plugs from your airways Remove a foreign object from your airways Widen (dilate) an airway that is blocked or narrowed Drain an abscess Treat cancer using a number of different techniques Wash out an airway (therapeutic lavage)

Respiratory failure is a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, it may be classified as either hypoxemic or hypercapnic. Hypoxemic respiratory failure (type I) is characterized by an arterial oxygen tension (Pa O2) lower than 60 mm Hg with a normal or low arterial carbon dioxide tension (Pa CO2). This is the most common form of respiratory failure, and it can be associated with virtually all acute diseases of the lung, which generally involve fluid filling or collapse of alveolar units. Some examples of type I respiratory failure are cardiogenic or noncardiogenic pulmonary edema, pneumonia, and pulmonary hemorrhage. Hypercapnic respiratory failure (type II) is characterized by a PaCO2 higher than 50 mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air. The pH depends on the level of bicarbonate, which, in turn, is dependent on the duration of hypercapnia. Common etiologies include drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders (eg, asthma and chronic obstructive pulmonary disease [COPD]).Respiratory failure may be further classified as either acute or chronic. Although acute respiratory failure is characterized by life-threatening derangements in arterial blood gases and acid-base status, the manifestations of chronic respiratory failure are less dramatic and may not be as readily apparent. Acute hypercapnic respiratory failure develops over minutes to hours; therefore, pH is less than 7.3. Chronic respiratory failure develops over several days or longer, allowing time for renal compensation and an increase in bicarbonate concentration. Therefore, the pH usually is only slightly decreased.The distinction between acute and chronic hypoxemic respiratory failure cannot readily be made on the basis of arterial blood gases. The clinical markers of chronic hypoxemia, such as polycythemia or cor pulmonale, suggest a long-standing disorder. Etiology : These diseases can be grouped according to the primary abnormality and the individual components of the respiratory system (eg, CNS, peripheral nervous system, respiratory muscles, chest wall, airways, and alveoli).A variety of pharmacologic, structural, and metabolic disorders of the CNS are characterized by depression of the neural drive to breathe. This may lead to acute or chronic hypoventilation and hypercapnia. Examples include tumors or vascular abnormalities involving the brain stem, an overdose of a narcotic or sedative, and metabolic disorders such as myxedema or chronic metabolic alkalosis. Common causes of type I (hypoxemic) respiratory failure include the following: COPD Pneumonia Pulmonary edema Pulmonary fibrosis Asthma Pneumothorax Pulmonary embolism Pulmonary arterial hypertension Pneumoconiosis Granulomatous lung diseases Cyanotic congenital heart disease Bronchiectasis

Acute respiratory distress syndrome (ARDS) Fat embolism syndrome Kyphoscoliosis,Obesity Common causes of type II (hypercapnic) respiratory failure include the following: COPD Severe asthma Drug overdose Poisonings Myasthenia gravis Polyneuropathy Poliomyelitis Primary muscle disorders Porphyria Cervical cordotomy Head and cervical cord injury Primary alveolar hypoventilation Obesity-hypoventilation syndrome Pulmonary edema ARDS Myxedema Tetanus Symptoms : Respiratory failure is accompanied by a number of symptoms including: Bluish coloration of the lips or fingernails Confusion or loss of consciousness Fainting or change in level of consciousness or lethargy Fatigue Irregular heart rate (arrhythmia) Rapid breathing (tachypnea) or shortness of breath Dangerous Symptoms : Bluish coloration of the lips or fingernails Change in level of consciousness or alertness, such as passing out or unresponsiveness Rapid heart rate (tachycardia) Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, or choking Physical Examination :Asterixis may be observed with severe hypercapnia. Tachycardia and a variety of arrhythmias may result from hypoxemia and acidosis. Cyanosis, a bluish color of skin and mucous membranes, indicates hypoxemia Dyspnea, an uncomfortable sensation of breathing, often accompanies respiratory failure. Both confusion and somnolence may occur in respiratory failure. Myoclonus and seizures may occur with severe hypoxemia. Polycythemia is a complication of longstanding hypoxemia. Pulmonary hypertension frequently is present in chronic respiratory failure. Alveolar hypoxemia potentiated by hypercapnia causes pulmonary arteriolar constriction. If chronic, this is accompanied by hypertrophy and hyperplasia of the affected smooth muscles and narrowing of the pulmonary arterial bed.

Lab Tests: A complete blood count (CBC) may indicate anemia, which can contribute to tissue hypoxia, whereas polycythemia may indicate chronic hypoxemic respiratory failure. Abnormalities in electrolytes such as potassium, magnesium, and phosphate may aggravate respiratory failure and other organ function. Measuring serum creatine kinase with fractionation and troponin I helps exclude recent myocardial infarction in a patient with respiratory failure. An elevated creatine kinase level with a normal troponin I level may indicate myositis, which occasionally can cause respiratory failure. In chronic hypercapnic respiratory failure, serum levels of thyroid-stimulating hormone (TSH) should be measured to evaluate the possibility of hypothyroidism, a potentially reversible cause of respiratory failure.
Instrumental Test : Chest radiography is essential in the evaluation of respiratory failure because it frequently reveals the cause (see the images below). However, distinguishing between cardiogenic and noncardiogenic pulmonary edema is often difficult. Increased heart size, vascular redistribution, peribronchial cuffing, pleural effusions, septal lines, and perihilar bat-wing distribution of infiltrates suggest hydrostatic edema; the lack of these findings suggests acute respiratory distress syndrome (ARDS). Echocardiography need not be performed routinely in all patients with respiratory failure. However, it is a useful test when a cardiac cause of acute respiratory failure is suspected.The findings of left ventricular dilatation, regional or global wall motion abnormalities, or severe mitral regurgitation support the diagnosis of cardiogenic pulmonary edema. A normal heart size and normal systolic and diastolic function in a patient with pulmonary edema would suggest ARDS.Echocardiography provides an estimate of right ventricular function and pulmonary artery pressure in patients with chronic hypercapnic respiratory failure. Pulmonary Functions Tests :Patients with acute respiratory failure generally are unable to perform PFTs; however, these tests are useful in the evaluation of chronic respiratory failure.Normal values for forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) suggest a disturbance in respiratory control. A decrease in the FEV1 -to-FVC ratio (FEV1/FVC) indicates airflow obstruction, whereas a reduction in both FEV1 and FVC and maintenance of FEV1/FVC suggest restrictive lung disease.Respiratory failure is uncommon in obstructive diseases when FEV1 is greater than 1 L and in restrictive diseases when FVC is greater than 1 L. Complications :Of acute respiratory failure may be pulmonary, cardiovascular, gastrointestinal (GI), infectious, renal, or nutritional. Common pulmonary complications of acute respiratory failure include pulmonary embolism, barotrauma, pulmonary fibrosis, and complications secondary to the use of mechanical devices. Patients are also prone to develop nosocomial pneumonia. Regular assessment should be performed by periodic radiographic chest monitoring. Pulmonary fibrosis may follow acute lung injury associated with ARDS. High oxygen concentrations and the use of large tidal volumes may worsen acute lung injury. Common cardiovascular complications in patients with acute respiratory failure include hypotension, reduced cardiac output, arrhythmia, pericarditis, and acute myocardial infarction. The major GI complications associated with acute respiratory failure are hemorrhage, gastric distention, ileus, diarrhea, and pneumoperitoneum. Stress ulceration is common in patients with acute respiratory failure; the incidence can be reduced by routine use of antisecretory agents or mucosal protectants. Acute renal failure and abnormalities of electrolytes and acid-base homeostasis are common in critically ill patients with respiratory failure. The development of acute renal failure in a patient with acute respiratory failure carries a poor prognosis and high mortality.

Nutritional complications include malnutrition and its effects on respiratory performance and complications related to administration of enteral or parenteral nutrition. Complications associated with nasogastric tubes, such as abdominal distention and diarrhea, also may occur.

19- Aspiration and examining of pleural fluid;(KAITLARDA) 20- ECG rhythm disorders, disturbances in the conduction, pathological changes in patients with angina and myocardial infarction; (KAITLARDA) 21- Functional and instrumental methods of examining of the heart veloergometry, echocardiography, scintigraphy, catheterization with angiography; (KAITLARDA) 22-Functional examining of the kidneys test for concentration and dilution of the urine, clearance tests; radiological tests diagnostic evaluation; (KAITLARDA) 23- Instrumental methods for examining of the alimentary tract gastroscopy, The sequence of examining the abdomen changes according to the age and cooperativeness of the child. Frequently all four types of assessments (inspection, auscultation, percussion and palpation) are performed at different times. For example, the medical practitioner may auscultate for bowel sounds following evaluation of heart and lung sounds at the beginning of the examination when the child is quiet. Percussion usually follows lung percussion, and palpation may be done toward the end of the examination when the child is relaxed and more trusting of the medical practitional. For descriptive purposes the abdominal cavity is divided into four compartments or quadrants by drawing a vertical line midway from the sternum to the pubic symphysis and a horizontal line across the abdomen through the umbilicus. This method of division actually includes the pelvic cavity. Each section is designated as follows: Right upper quadrant (RUQ), Right lower quadrant (RLQ), Left upper quadrant (LUQ), Left lower quadrant (LLQ). Percussion Percussion of the abdomen is performed in the same manner as percussion of the lungs and heart. Normally, dullness or flatness is heard on the right side at the lower costal margin because of the location of the Liver. Tympany is typically heard over the stomach on the left side and usually in the rest of the abdomen. An unusually tympanitic sound, like the beating of a tight drum, usually breathing. However, it can also denote a pathoilogic condition such as low intestinal obstruction or paralytic ileus. Lac of tympany may occur normally when the stomach is full after a meal, but in other situations it may denote the presence of fluid or solid masses. Palpation

Two types of palpation are performed, superficial and deep. In superficial palpation a doctor lightly places the hand against the skin and feels each quadrant, noting any areas of tenderness, muscle tone, and superficial lesions, such as cysts. Superficial palpation is often perceived as "tickling" by the child. Which can interfere with its effectiveness, The nurse can avoid this problem by having the child "help" with the palpation by placing him with statements such as, "I am trying to feel what you had for lunch". Admonishing the child to stop laughing only draws attention to the sensation and decreases cooperation. Positioning the child in supinated position with the legs flexed at the hips and knees helps relax the abdominal muscles. Tenderness anywhere in the abdomen during superficial palpation is always noted. There are two types of abdominal pain: 1. Visceral, which arises from the viscera or internal organs such as the intestines, and 2. Somatic, which arises from the walls or linings of the abdominal cavity such as the peritoneum. Visceral pain is usually dull, poorly localized, and difficult for the patient to describe. Somatic pain is generally sharp, well localized and more easily described. When assessing abdominal pain, it is important to remember that the child will often respond with an "all-or-none" reaction- either there is no pain or great pain. Therefore all aspects of the examination must be carefully considered when ruling out conditions such as appendicitis. A special phenomenon called rebound tenderness, or Blumberg's sign, may be performed if the child complains of abdominal pain. It is performed by pressing firmly over the part of the abdomen distal to the area of tenderness. When the pressure is suddenly released, the child feels pain in the original area of tenderness. This response is only found when the peritoneum overlying a diseased visceral or organ is inflamed, such as in appendicitis. Deep palpation is used for palpating organs and large blood vessels and for detecting masses and tenderness that were not discovered during superficial palpation. If the child complains of abdominal pain, the area of the abdomen is palpated last. Normally, palpation of the mid-epigastrium causes pain as pressure is exerted over the aorta, but this should not be confused with visceral or somatic tenderness. The doctor palpates the abdominal organs by pressing them with a free hand, which is placed on the child's back. Palpation begins in the lower quadrants and proceeds upwards. In this way, the edge of an enlarged liver or spleen is not missed. Except for

palpating the liver, successful identification of other organs, such as the spleen, kidney, and part of the colon, requires considerable practice with tutored supervision. The lower edge of the liver is sometimes palpable in infants and young children as a superficial mass 1 to 2cm (1/2 to inch) below the right costal margin (the distance is sometimes measured in fingerbreadths). If the liver is palpable 3cm (1/4 inches) or 2 fingerbreadths below the costal margin, It is considered enlarged and this finding is referred to a physician. Normally the liver descends during inspiration as the diaphragm moves downward. This downward displacement should not be mistaken for a sign of hepatomegaly. In older children the liver frequently is not palpable, although its lower edge can be estimated by percussing dullness at the costal margin. The spleen is palpated by feeling it between the hand placed against the back and the one palpating the left upper quadrant. The spleen is much smaller than the liver and positioned behind the fundus of the stomach. The tip of the spleen is normally felt during inspiration as it descends within the abdominal cavity. It is sometimes palpable 1 to 2 cm below the left costal margin in infants and young children. A spleen that is readily palpated more than 2cm below the right costal margin is enlarged and is always reported for further medical investigation. Other anatomical structures that are sometimes palpable in children include the cecum, and sigmoid colon. The cecum is a soft, gas-filled mass in the right lower quadran. The sigmoid colon is left as a sausage-shaped mass that is freely movable over the pelvic brim in the left lower quadrant and is normally tender. Although most of these structures are not routinely felt, one should be aware of their relative location and characteristics in order not to mistake them for abnormal masses. The most common palpable lower quadrant because with constipation the left colon fills with stool and gas until the ileocecal valve is reached. The the cecum becomes distended, causing pain, which may be erroneously associated with appendicitis. Special methods of investigation Laboratory examination 1. Routine blood examination 2. Urine tests (bile pigments, ketonuria) 3. Biochemical analysis (bilirubin total, unconjugated and conjugated bilirubin, protein, cholesterol, AlAt, AsAt, amylase, trypsin and lipase) 4. Biochemical analysis of Urine for diastase. Disorders 1. Syndrome of cholistasis increased level of total and conjugated bilirubin and cholesterol).

2. Syndrome of cytolysis (increased level of AsAt, AlAt, LDG) 3. Syndrome of dysfunction of pancreas (increased level of amylase, trypsin, lipase) 4. Chain polymerizes reaction for virus of hepatitis A, B, C 5. Examination of feces for intestinal parasites (ascarides, lamblia cysts, enterobiosis) 6. Copogram Indigested muscular fibers Steatorrhea Lientery Bacteria in the feces Instrumental methods of examination 1. Esophagogastroduodenoscpy 2. Ultrasound investigation 3. Intragastric pH-metry 4. Colonoscopy 5. Procto(sigmoido)scopy 6. Artificial contrast study of gastrointestinal system 7. Laparoscopy 8. Irrigoscopy and irrigography 9.Gastroscopy A gastroscopy is a test where an operator (a doctor or nurse) looks into the upper part of your gut (the upper gastrointestinal tract). The upper gut consists of the oesophagus (gullet), stomach and duodenum. The operator uses an endoscope to look inside your gut. Therefore, the test is sometimes called endoscopy.An endoscope is a thin, flexible, telescope. It is about as thick as a little finger. The endoscope is passed through the mouth, into the oesophagus and down towards the stomach and duodenum. Colonoscopy is a procedure used to see inside the colon and rectum. Colonoscopy can detect inflamed tissue, ulcers, and abnormal growths. The procedure is used to look for early signs of colorectal cancer and can help doctors diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss. A rectoscopy is one of many components under endoscopy, which basically means looking inside the body for medical reasons. The instrument used is called an endoscope. This device goes inside the organ to properly observe from the inside. A rectoscopy specifically is the endoscopy of the rectum, which is an organ used in defecation. Essentially the endoscope is inserted into a place where the "sun don't shine," so to speak. Normal laboratory values of biochemical analysis of blood Glucose 3.33-5.55 mmol/L Bilirubin total 8.5-2.0 mcmol/L

Unconjugated 2/3 of total Conjugated 1/3 of total Protein total 60.0-80.0g/L ALT 0.1-0.75 mcmol/g/L AST 0.1-0.45 mcmol/g/L Amylase 16-32 dye units/L A number of gastrointestinal disorders are caused by disturbances in motor function. Some such as Hirschsprung's disease, produce typical signs of obstruction and are alternately classified as obstructive disorders. 24- Laboratory tests in patients with liver diseases diagnostic evaluation;
The diagnosis of liver diseases depends upon a combination of history, physical examination, laboratory testing and sometimes radiological studies and biopsy. Only a physician who knows all of these aspects of a specific case can reliably make a diagnosis. Alanine aminotransferase (ALT) ALT is an enzyme produced in hepatocytes, the major cell type in the liver. ALT is often inaccurately referred to as a liver function test, however, its level in the blood tells little about the function of the liver. The level of ALT in the blood (actually enzyme activity is measured in the clinical laboratory) is increased in conditions in which hepatocytes are damaged or die. As cells are damaged, ALT leaks out into the bloodstream. All types of hepatitis (viral, alcoholic, drug-induced, etc.) cause hepatocyte damage that can lead to elevations in the serum ALT activity. Aspartate aminotransferase (AST) AST is an enzyme similar to ALT but less specific for liver disease as it is also produced in muscle and can be elevated in other conditions (for example, early in the course of a heart attack). AST is also inaccurately referred to as a liver function test by many physicians. In many cases of liver inflammation, the ALT and AST activities are elevated roughly in a 1:1 ratio. In some conditions, such as alcoholic hepatitis or shock liver, the elevation in the serum AST level may higher than the elevation in the serum ALT level. Alkaline phosphatase Alkaline phosphatase is an enzyme, or more precisely a family of related enzymes, produced in the bile ducts, intestine, kidney, placenta and bone. An elevation in the level of serum alkaline phosphatase (actually enzyme activity is measured in the clinical laboratory), especially in the setting of normal or only modestly elevated ALT and AST activities, suggests disease of the bile ducts. Serum alkaline phosphatase activity can be markedly elevated in bile duct obstruction or in bile duct diseases such as primary biliary cirrhosis or primary sclerosing cholangitis. Gamma-glutamyltranspeptidase (GGT)An enzyme produced in the bile ducts that, like alkaline phosphatase, may be elevated in the serum of patients with bile duct diseases. Elevations in serum GGT, especially along with elevations in alkaline phosphatase, suggest bile duct disease. Measurement of GGT is an extremely sensitive test, however, and it may be elevated in virtually any liver disease and even sometimes in normal individuals. Albumin Albumin is the major protein that circulates in the bloodstream. Albumin is synthesized by the liver and secreted into the blood. Low serum albumin concentrations indicate poor liver function. Prothrombin time (PT) Many factors necessary for blood clotting are made in the liver. When liver function is severely abnormal, their synthesis and secretion into the blood is decreased. The prothrombin time is a type of blood clotting test performed in the laboratory and it is prolonged when the blood concentrations of some of the clotting factors made by the liver are low. In chronic liver diseases,

the prothrombin time is usually not elevated until cirrhosis is present and the liver damage is fairly significant. In acute liver diseases, the prothrombin time can be prolonged with severe liver damage and return to normal as the patient recovers. Platelet count Platelets are the smallest of the blood cells (actually fragments of larger cells known as megakaryocytes) that are involved in clotting. In some individuals with liver disease, the spleen becomes enlarged as blood flow through the liver is impeded. Serum protein electrophoresis In this test, the major proteins in the serum are separated in an electric field and their concentrations determined. The four major types of serum proteins whose concentrations are measured in this test are albumin, alpha-globulins, beta-globulins and gamma-globulins.

25 -Abdominal ultrasound, liver biopsy, CT scanning, MRI diagnostic abilities; of the methods;

What is Ultrasound Imaging of the Abdomen? Ultrasound imaging, also called ultrasound scanning or sonography, involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound examinations do not use ionizing radiation (as used in x-rays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels. Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.An abdominal ultrasound produces a picture of the organs and other structures in the upper abdomen.A Doppler ultrasound study may be part of an abdominal ultrasound examination.Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck. What are some common uses of the procedure? Abdominal ultrasound imaging is performed to evaluate the: kidneys liver gallbladder pancreas spleen abdominal aorta and other blood vessels of the abdomen Ultrasound is used to help diagnose a variety of conditions, such as: abdominal pain or distention. abnormal liver function. enlarged abdominal organ. stones in the gallbladder or kidney. an aneurysm in the aorta. Additionally, ultrasound may be used to provide guidance for biopsies. Doppler ultrasound images can help the physician to see and evaluate: blockages to blood flow (such as clots). narrowing of vessels (which may be caused by plaque). tumors and congenital vascular malformation.

A liver biopsy is a procedure in which a small needle is inserted into the liver to collect a tissue sample. The tissue is then analyzed in a laboratory to help doctors diagnose a variety of disorders and diseases in the liver. A liver biopsy is most often performed to help identify the cause of;

Persistent abnormal liver blood tests (liver enzymes). Unexplained yellowing of the skin (jaundice). A liver abnormality found on ultrasound, CT scan, or nuclear scan. Unexplained enlargement of the liver. What is CT Scanning of the Body? CT scanningsometimes called CAT scanningis a noninvasive medical test that helps physicians diagnose and treat medical conditions.CT scanning combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor, printed or transferred to a CD. CT scans of internal organs, bones, soft tissue and blood vessels provide greater clarity and reveal more details than regular x-ray exams. one of the best and fastest tools for studying the chest, abdomen and pelvis because it provides detailed, cross-sectional views of all types of tissue. often the preferred method for diagnosing many different cancers, including lung, liver, kidney and pancreatic cancer, since the image allows a physician to confirm the presence of a tumor and measure its size, precise location and the extent of the tumor's involvement with other nearby tissue. an examination that plays a significant role in the detection, diagnosis and treatment of vascular diseases that can lead to stroke, kidney failure or even death. CT is commonly used to assess for pulmonary embolism (a blood clot in the lung vessels) as well as for abdominal aortic aneurysms (AAA). invaluable in diagnosing and treating spinal problems and injuries to the hands, feet and other skeletal structures because it can clearly show even very small bones as well as surrounding tissues such as muscle and blood vessels. In pediatric patients, CT is rarely used to diagnose tumors of the lung or pancreas as well as abdominal aortic aneurysms. For children, CT imaging is more often used to evaluate: lymphoma neuroblastoma kidney tumors congenital malformations of the heart, kidneys and blood vessels Magnetic resonance imaging (MRI) is a type of scan used to diagnose health conditions that affect organs, tissue and bone. MRI scanners use strong magnetic fields and radio waves to produce detailed images of the inside of the body. An MRI scanner is a large tube that contains a series of powerful magnets. You lie inside the tube during the scan. MR imaging of the body is performed to evaluate: organs of the chest and abdomenincluding the heart, liver, biliary tract, kidneys, spleen, bowel,pancreas and adrenal glands. pelvic organs including the reproductive organs in the male (prostate and testicles) and the female (uterus, cervix and ovaries). blood vessels (MR Angiography). breasts. Physicians use the MR examination to help diagnose or monitor treatment for conditions such as: tumors of the chest, abdomen or pelvis. certain types of heart problems.

blockages, enlargements or anatomical variants of blood vessels, including the aorta, renal arteries, and arteries in the legs. diseases of the liver, such as cirrhosis and tumors, and that of other abdominal organs, including the bile ducts, gallbladder, and pancreatic ducts. diseases of the small intestine, colon, rectum and anus. cysts and solid tumors in the kidneys and other parts of the urinary tract. tumors and other abnormalities of the reproductive organs (e.g., uterus, ovaries, testicles, prostate). causes of pelvic pain in women, such as fibroids, endometriosis and adenomyosis. suspected uterine congenital abnormalities in women undergoing evaluation for infertility. breast cancer and implants. fetal assessment in pregnant women.

26- Functional examining of the endocrine system; Thyroid Gland Examination : GENERAL APPEARANCE: - Weight loss. - Anxiety. - Frightened facies (thyroid stare) Hands : Onycholysis (Plummers nails) particularly on the ring finger. Rarely seen in Graves disease. - Thyroid acropachy (clubbing). - Fine tremors (sympathetic over activity). - Moisture & warmth (sympathetic over activity). - Palmer erythema. VITAL SIGNS: .RADIAL PULSE: . Sinus tachycardia. Collapsing character (high cardiac output). Irregularly irregular: atrial fibrillation. Regular with periods of irregularity: extrasystole. .BLOOD PRESSURE. .TEMPERATURE. . RESPIRATORY RATE. ARMS: - Proximal myopathy (ask the patient to raise the arms above the head). - Exaggerated reflexes (esp. in relaxation phase). EYES : XOPHTHALMOS (PROPTOSIS): Protrusion of the eyeball out of the orbit (occurs bilaterally only in Graves disease). - Sclera visible below or all around the iris. - Patient can look up without wrinkling the forehead. - Difficulty in converging. - Patient cannot close the eyelids. - Eyeball is visible anterior to superior orbital margin. CHEMOSIS : Thickening, crinkling, oedema & opacity of conjunctiva particularly over the insertion of the lateral rectus muscle.

 CONJUNCTIVITIS: CORNEAL ULCERATION: due to inability to close the eyelids. OPTIC ATROPHY: due to optic nerve stretching. OPHTHALMOPLEGIA: Patient cannot look upwards & outwards. LID LAG: The upper eyelid cannot keep pace with the eyeballs as it follows a finger moving from above downwards. LID RETRACTION: Sclera visible above the superior limbus of the iris. LEUKOTRICHIA: White discoloration of the eyelashes. NECK: INSPECTION: Look at the front & sides of the neck & decide if there is localized or general swelling of the gland. - Swelling (enhanced by asking the patient to swallow sips of water):
Shape (nodular or diffuse). Movement during swallowing (only a goiter or thyroglossal cyst will rise during swallowing). Inferior border.

- Scars (thyroidectomy scar). - Prominent veins (over the upper part of the chest, often accompanied by JVP. Suggest retrosternal extension of the goiter thoracic inlet syndrome-). - Erythema of skin (in case of suppurative thyroiditis). There is diffuse thyroid swelling that moves freely with swallowing & its inferior border is visible.No scars, prominent veins or erythema of skin. PALPATION: begun from behind. - Size: look for the lower border, if absent, may be retrosternal extension). - Site: - Shape: Diffuse enlargement. Solitary nodule: - Location. - Size. - Consistency: Soft: simple goiter. Rubbery hard: Hashimotos thyroiditis. Stony hard node: carcinoma, calcification in a cyst, fibrosis, or Riedels thyroiditis. Tenderness. Mobility. Multinodular. - Surface: - Temperature: thyroiditis. - Tenderness: Thyroiditis (subacute or rarely suppurative), bleeding into cyst or carcinoma. - Texture: - Thrill: in thyrotoxicosis. - Consistency: firm or stony hard. - Relation to surrounding structures: tethering or fixation to overlying skin or underlying tissues in thyroid carcinoma. - State of regional L.N: enlarged in carcinoma.

- State of local tissues (due to malignancy infiltration by thyroid carcinoma): Arteries: bruits over the carotids. Veins: venous hum. NOW, move to the front. Note the position of the trachea, which may displaced by a retrosternal gland. PERCUSSION: Percuss the upper part of the manubrium from one side to the other. If percussion notes changed, this may indicate retrosternal extension. AUSCULTATION: Listen for a bruit over each lobe which occur in: - Hyperthyroidism. - Using of antithyroid drugs. CHEST: *Thoracic inlet obstruction Pembertons sign: by asking the patient to lift both arms as high as possible. Wait for few minutes: -Congestion of the face (plethora). -Cyanosis. -Respiratory distress & inspiratory stridor. -Neck venous distention (venous congestion). *This occurs with retrosternal goiter or any retrosternal mass. - Gynaecomastia (occasionally with thyrotoxicosis, or with panhypopituitarism). - Systolic flow murmurs (due to cardiac output). - Signs of CHF esp. in elderly (precipitated by thyrotoxicosis). THE LEGS: * Look for pretibial myxoedema (bilateral firm elevated dermal nodules & plaques which can be pink, brown, or skin colored). -Due to accumulation of mucopolysaccharide. -This is occurs only in Graves disease & not in hypothyroidism. *Test for proximal myopathy & reflexes in the legs. DIABETES MELLITUS EXAMINATION: If FBS 7.8 mmol/L. or the 2 hour postprandial BSL of 11.1 mmol/L or more in more than one occasion. - Primary: either type I or type II. - Secondary: hormone induced state (acromegally, Cushings syndrome, phaeochromocytoma, and glucagonoma). - Drugs: steroid, thiazide, phenytoin, the contraceptive pills, and diazoxide). - Pancreatic disease (carcinoma, chronic pancreatitis, haemochromatosis). GENERAL SYMPTOMS: Polyuria, polydiapsia, polyphagia, blurred vision, weakness, tiredness, lethargy, infections, groin itch, weight loss, disturbance of conscious state, rash (pruritis vulvae, balanitis). GENERAL APPEARANCE: -Evidence of dehydration (osmotic diuresis). -Obesity (type II DM). -Recent weight loss (evidence of uncontrolled glycosuria). -Abnormal endocrine facies (acromegally, Cushings syndrome). -Pigmentation (haemochromatosis bronze diabetes). -Kussmals breathing Air Hanger (diabetic ketoacidosis) LOWER LIMBS: INSPECTION: SKIN - Hairless & atrophied (small vessels vascular diseases & resultant ischemia).

- Leg ulcers on the toes or any pressure areas- (ischemia, peripheral neuropathy). - Skin infections boils, cellulitis & fungal infections ( glucose, ischemia). - Pigmented scar (late diabetic dermopathy). - Necrobiosis Lipoidica Diabeticorum: over the skin & it is a central yellow scarred area, which surrounded by a red margin when the condition is active. - Insulin injection sites (usually in the thigh): may associated with localized fat atrophy &/or hypertrophy. MUSCLE WASTING: -Note any Quadriceps muscle wasting due to femoral nerve mononeuropathy. This is called Diabetic Amyotrophy. KNEE: - Rare Charcots joint : grossly deformed & disorganized joint due to loss of proprioception or pain or both. PALPATION : Injection sites for fat atrophy or hypertrophy. - Feel all peripheral pulses, temperature, and tests the capillary return if (peripheral vascular disease). NEUROLOGICAL EXAMINATION: - Check for sensation, muscle power & tap reflexes. UPPER LIMBS: Nail: for signs of candidal infections. -Inspect & feel for the injection sites over the forearm. -Take blood pressure lying & standing autonomic neuropathy which may leads to postural hypotension. FACE EXAMINATION: EYES: Visual acuity, which may be: -Permanent: due to retinal diseases. T-emporarily: due to disturbed the shape of the lens associated with hyperglycemia & water retention. EARS: -Evidence of Malignant Otitis Externa caused by Pseudomonas Aeruginosa. -Facial nerve palsy (in 50 %). MOUTH -Evidence of candidal infections. NECK & SHOULDERS: -Examine carotid artery for evidence of vascular diseases. -Check for the thickening of the upper back & shoulders (evidence of Scleroderma). -Acanthosis nigricans (in insulin resistant cases). CHEST : For signs of infections. ABDOMEN: Palpate hepatomegally due to fatty infiltration or due to haemochromatosis. 27- Functional examining of bones and joints;(KAITLARDA)