Investigations in family doctors practice

1. Investigations in family doctors practice doc. Butvyn S.M. Polyclinical affairs and family doctors department Medical faculty

2. Main methods of instrumental investigations: • Electrocardiography (ECG) • Radiology • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Angiography • Radionuclide scanning

3. Main methods of instrumental investigations: • Ultrasonography (Echo) • Endoscopy • Biopsy • Lung function testing

4. Electrocardiography

5. Indicated to electrocardiography • To elucidate cardiac arrhythmias and conduction defects • To diagnose and localise myocardial hypertrophy, ischaemia or infarction • To diagnose electrolyte imbalance and toxicity of certain drugs

6. Exercise (stress) ECG • By performing an ECG during progressively increasing exercise (usually on a treadmill) • Indication to detect stress-provoked arrhythmias or evidence of ischaemia • Contraindication: unstable angina, decompensated heart failure, severe hypertension

7. Ambulatory ECG (Holter monitoring) • Continuous recording of one or more ECG leads to a small portable solid state or tape recorder • Indication: detecting transient episodes of arrhythmias or of ischaemia

8. Radiology • Plain chest radiograph • Plain abdomen radiograph • Barium studies (barium swallow and meal examination, barium enema)

9. Plain chest radiograph • To detect lung pathologies (pneumonia, carcinoma, pulmonary tuberculosis, ect.) • To detect heart pathologies (size and shape of the heart, state of the pulmonary blood vessels and lung fields )

10. Dilatation of individual cardiac chambers • Left atrial dilatation results in prominence of the left atrial appendage, a double cardiac shadow to the right of the sternum and widening of the angle of the carina as the left main bronchus is pushed upward. • Right atrial enlargement projects from the right heart border towards the right lower lung field. • Left ventricular dilatation causes prominence of the left lower heart border and enlargement of the cardiac silhouette. LV hypertrophy does not cause overall cardiac enlargement unless heart failure ensues. • Right ventricular dilatation increases heart size and displaces the apex upward. Differentiation from LV dilatation may be difficult on chest radiograph.

11. Plain abdomen radiograph • Show the normal soft tissue shadows due to the liver, spleen and kidneys • Gas in the intestine • Fluid levels. • Areas of opacification due to stones or to calcification in the liver, pancreas, cysts or blood vessels

12. Barium swallow and meal examination • Oesophagus - disorder of motility, a filling defect caused by a tumour or varices, a stricture, a diverticulum or a hiatus hernia • Stomach – to detect ulcer, cancers (except infiltrating carcinoma) • Small bowel - to detect structural abnormalities such as diverticula or strictures

13. Barium enema • The colon must be meticulously cleared of faeces by means of laxatives followed by a cleansing enema just before the barium enema. • Barium alone or, for double-contrast examination, barium and air, is run into the bowel through a self-retaining catheter. • Radiographs are taken with the colonic mucosa coated with barium and the lumen distended with air • Colonic mucosa can be studied in detail and polyps or small tumours identified. • In inflammatory bowel disease mucosal abnormalities are readily recognised.

14. Endoscopy • Oesophagogastroduodenoscopy (EGDS) • Sigmoidoscope • Endoscopic retrograde cholangiopancreatography (ERCP) • Laparoscopy • Laryngoscopy • Bronchoscopy • Mediastinoscopy • Cystoscopy

15. Diagnostic possibilities of the endoscopy • To exam oesophagus, stomach, duodenum, colon, bronchi, larynx, mediastinum, abdomen cavity • To take biopsy • To do therapeutic procedures such as removal of a polyp

16. Contraindications to endoscopy • Severe hemorrhagia • Psychiatry diseases • Comas • Lung or heart insufficiency of III st. • IHD • Severe hypertension • Severe thyreotoxicosis

17. Bronchoscopy • Detect structural changes, such as distortion or obstruction • To biopsy abnormal tissue in the bronchial lumen or wall • Bronchial brushings, washings or aspirates can be taken for cytological or bacteriological examination.

18. Prepare patient to the EGDS and bronchoscopy • The planned EGDS conduct on an empty stomach in the morning. • Local anaesthesia of cavity of mouth and pharynx (greasing of mucus shell by a 3% solution of dicain, rinse of mouth by 0,25% solution of dicain or dispersion from the sprayer of a 3% solution of dicain with addition of 2-3 drops of 0,1% solution of adrenalin. • At a necessity after 15-20 min to research under a skin enter 1 ml 2 % solution of promedol, and 0,5-1 ml 0,1% solution of atropine sulfate

19. Normal mucosa of oesophagus

20. Normal mucosa of duodenum

21. Normal mucosa bulbus of duodenum

22. Erosive bulbitis

23. Main types of chronic gastritis (endoscopic): • Superficial gastritis • Atrophic gastritis • Hypertrophic gastritis

24. Superficial gastritis

25. Atrophic gastritis

26. Hypertrophic gastritis

27. Erosive gastritis

28. Peptic ulcer in active stage

29. Peptic ulcer in reparation stage

30. Peptic ulcer in scary stage

31. Possible complications of EGDS • perforation of the oesophaguss or stomach whilst passing the instrument or during biopsy • the inhalation of secretions • cardiac arrhythmias or arrest • transmission of infections

32. Ultrasound investigation

33. Prepare patient to the abdominal ultrasonograhy • Three days before the inspection to apply measures for reduction of formation of gas • To exclude from a meal the milk, brown bread, fresh fruits and vegetables, fruit juices • To the persons, that suffer by flatulence, limitation of products, that cause flatulence on two-three days of the use of polyenzyme drugs (festal, digestal, mezym-forte), absorbent carbon is appointed, decoction of chamomile • The inspection is conducted on an empty stomach (necessarily previous starvation about 12 hours) • In the extreme case the research is conducted off the hand.

34. Gall bladder ultrasound investigation • mostly determine the Gall bladder (GB) on 5-6 sm rihgt from middleline • form rounded or prolate (depending on a cut) • walls GB appear by surrounding fabrics or structure of organ which he is designed on(mostlylivers) • the thickness of wall GB does not exceed 3 mm • a cavity of GB is free • middle sizes 5-6 x 2-3 sm.

35. Gall bladder ultrasound investigation (normal)

36. Echography sings of chronic cholecystitis

37. Gallstones

38. Diagnostic values of liver ultrasound investigation • size of liver • contours of liver • the state of intrahepatic bile ducts • presence of focal changes in a liver • presence of free liquid in an abdominal and pleura region • the state of intrahepatic vein net

39. Liver ultrasound investigation (normal)

40. Echography sings of chronic hepatitis • change of sizes of liver; • change of closeness of liver; • possible expansion of portal vein

41. Liver ultrasound investigation (chronic hepatitis)

42. Echography sings of cirrosis of the liver Diagnostic meaningfulness only at high active and of long duration forms. • heterogeneous increase or reduction of liver • knotted unequal surface • heterogeneous ehostructure

43. Cirrosis of the liver

44. Secondary malignant tumors in the liver

45. Ultrasound investigation of the pancreas (normal)

46. Chronic pancreatitis

47. Chronic pancreatitis

48. Diagnostic value of the renal ultrasound • To assess overall renal size and cortical thickness • To distinguish solid tumours from cysts • Excellent screening test for polycystic kidney disease • In investigation of suspected malignant renal tumours ultrasound can give additional information by detecting extension of tumour to renal veins, vena cava, lymph nodes or liver

49. Diagnostic value of the renal ultrasound • It can demonstrate dilation of the renal pelvis and ureters, which may indicate urinary tract obstruction • To assess residual urine in the bladder after nicturition • Perinephric abscess or haematoma can be demonstrated • Calculi are usually detected but very small stones may be missed

50. Ultrasound investigation of the kidney (normal)