Ideal diagnostics

Tip of Iceberg

Ideal diagnostics

Diagnostic Investigations

Is investigations necessary ?

Only Clinical Evaluation = Management Is it Possible ?

Ideal diagnostics

TEAM EFFORT {Diagnostician & Therapeutician}

CONFIRMATORY DIAGNOSIS { INVESTIGATIONS}

TREATMENTMANAGEMENT

CLINICAL DIAGNOSIS{ PROVISIONAL DIAGNOSIS}

Ideal diagnostics

Diagnostic Need ??

DIAGNOSTICIAN{ RADIOLOGY / LABORATORY/

DOCTOR

PATIENT

NATUROPATHY

UNANIAYURVEDA

& SIDDHA

HOMEO

ALLOPATHY

FINALFINALDIAGNOSISDIAGNOSIS

Ideal diagnostics

Ideal diagnostics

Central Point

RADIOLOGY/ OTHER INVESTIGATIONS

ModernMedicine Ayush Naturopathy

Ideal diagnostics

Importance of Confirmatory Diagnosis

To Choose / Plan Appropriate method of Management

To initiate Early Treatment

To avoid late Complications

For Medico-legal Overcome

For Future Follow-up

Ideal diagnostics

Investigations

Radiology Lab Tests / Pathology - For all Systems Cardiac – ECG / Treadmill/ ECHO/ ANGIO Neuro- EEG/ ENMG Audiogram - ENT Bone densitometer- BONE Spirometry – Lung Capacity Endoscopy – Any Luminal Structure

Today ours focus is 1] What investigations to do ?

2] How to Write test ? View …

3] How to Read the Reports & Images ?

4] What to do Next ?

5] Follow-up tests needed or not ?

What investigations required for?

Headache : Skull X-Ray ; PNS ; CT Scan Giddiness : Audiometry ; C.Spine x-ray;

Carotid doppler Sinusitis : X-Ray PNS; CT Scan Stridor & URI in Children: X-ray adenoid Cough ; LRI : Chest X-Ray Dyspnea: ECG; PFT Dysphagia: Barium Swallow x-ray

Tests needed are Breast Swelling : USG Breast; X-Ray breast Neck Pain: C-Spine x-ray Shoulder Pain: C-Spine X-Ray & X-Ray

shoulder Restricted shoulder movements: X-Ray &

USG Scan Abd Pain; Dyspepsia;Vomiting;Bowel

disturbances : USG Scan; Barium; endoscopy

Nedded tests are Colicky pain abd: USG Scan; Urine R/E; Menstrual complaints: USG Scan; Male Infertility: Doppler Scrotum; Semen

test Femal Infertility: USG Scan;Follicular study;

HSG Erectile Dysfunction: Penile Doppler Leg swelling & Pain: Doppler limbs Numbness legs; DM : Limb arterial doppler

Symptoms based tests: Fits : EEG ; CT Scan; MRI Scan Backache: USG abd; X-Ray SPINE;MRI Occupational dyspnea: PFT Cancer Work-Up : PET Scan Neck Swelling : TFT ; USG Thyroid

RADIOLOGY

NUCLEARMEDICINE

RADIO-THERAPY

RADIO-DIAGNOSIS

Ideal diagnostics

Radiology Sub-divisions { RADIO-DIAGNOSIS}

X-Ray - Head; Neck; Chest ; Bones & Joints Ultrasound Scan - Abdomen; Pelvis;

Scrotum;Breast;Thyroid;Soft tissue lesions Colour Doppler Scan – Vascular Study CT Scan- Head; Neck; Chest;Spine& Joints MRI Scan- Brain;Spine;Joints PET Scan-{ Anatomy & Physiology} Neoplasms Workup INTERVENTIONAL Radiology – Vascular & Non-vascular

Chocolate Cyst Ovary

TB LUNGS

Meningioma

Radiology

Ideal diagnostics

Case Scenario : 1 40 yrs old male with acute onset of Pain Lt

shoulder with restricted movements following history of fall…

Could it be fracture ? Muscle tear ?? First to R/O Serious one fracture.. X-Ray Lt Shoulder what view? AP View… Normal What next?

X-Ray Left Shoulder AP View

Look for Bony Parts

Joint Space

Dislocation

Fracture

ULTRASOUND LT SHOULDER Muscular / Tendinous

Tear { Complete / Partial}

Tendinitis

Joint Effusion

Soft tissue swelling

MRI SCAN LEFT SHOULDER Confirmation of earlier

findings

Articular Cartilage / Ligamentous injury

Soft tissue details

Case Scenario : 2 Elderly male { 75 yrs } with C/O Chronic

Cough; Weight loss & Hemoptysis TB ? Neoplastic ?? Without diagnosis Symptomatic management

??? Advised Cheap & easily available test Chest X-Ray ; Which view PA View

Chest X-Ray PA View Right Lung Opacity Vessel ? LN?? Mass?

CT SCAN CHEST { HRCT} Mediastinal Window /

Lung Window

With or Without Contrast

Imagingwise looks like mass lesion

PET CT { Whole body} To Know the lesion

either as active / inactive

Spread to rest of the lung & rest of the body

Costlier & harmful

Ideal diagnostics

How to Write tests:

Positional Views

A P view

P A view

LATERAL view OBLIQUE view SPECIAL views { water’s view, axial view,lordotic

view ,skyline view, OPG, Mammogram}

Views The body Part closer to Cassette is area of

interest – denominated as second letter PA Means : “A”{ANTERIOR} Close to

Casette ; Area of Interest

How to read reports & Images

RADIOLOGY X-Ray { Conventional & Contrast } USG Scan Doppler Scan CT Scan MRI Scan PET Scan

Ideal diagnostics

X- Ray History X-Ray is Electromagnetic Ionic Radiation X-Ray is Produced from “X-Ray tube” First Invented by Wilhelm Roentgen in nov 8th

1895 X-Rays Captured by Photoelectric Plates / CR

Plates Images Developed by Darkroom Technique / CR

Technique X-Ray energy emission measured as mSv/ mGy

Ideal diagnostics

Formation of X-Rays

Ideal diagnostics

X-Ray Taking

Ideal diagnostics

Analogue CR X-ray

Ideal diagnostics

Significance of CR X-rays Digital form- Images so easily transferable

No Chemical used

Better Resolution- better image

Storage for longer time

Costlier

How to read Reports & Images:

X- Ray Terminology

Radio-opaque ; Opacity Radio-lucent Hyperlucency / Hypolucency Osteopenia / Osteoporosis Hyperostosis Spondylosis / Spondylolisthesis / Spondylitis Cartilage / Articular Surface

Ideal diagnostics

Ultrasound Terminology Echogenicity: [a] Iso-echoic = Same echoes as

Comparative structure [b] Hypo-echoic = Low-echoic = Sonolucent =

Sonopoor= echopoor [c] Hyper-echoic= Echogenic=echodense [d] Mixed echoic [e] Post-acoustic shadow / Post-acoustic

enhancement [f] Anechoic = echo-dropout [g] Valsalva manoeure [h] Compressibility

CT SCAN TERMINOLOGY

Hounsfield units ; Bone –Higher HU Density { iso ; hypo & Hyper} Plain { NECT} & Contrast { CECT} Contrast Dye : Ionic { Urovideo} Non-ionic { Iohexol}

Ideal diagnostics

X-Ray Bones

Bone Mineralization

Length & Width

Fracture

Tumour

Ideal diagnostics

osteopenia

Senility

Vit.D Deficiency

Hypo-parathyroidism

Hypocalcemia & Hypophosphatasia

HYPEROSTOSIS1. HYPERCALCEMIA STATE2. FLUOROSIS

Ideal diagnostics

LYTIC AREAS1. INFECTIVE2. PROLIFERATIVE DISORDER3. NEOPLASTIC

Ideal diagnostics

BLASTIC LESIONS

1. BENIGN OSTEOMA

2. NEOPLASTIC

3. SECONDARIES

Ideal diagnostics

FRACTURE Complete / Greenstick

With / without Displacement

Ideal diagnostics

X-Ray Skull

AP View Lateral View

X-Ray Skull

Ideal diagnostics

Ideal diagnostics

sella

mastoid

Ideal diagnostics

X-Ray Neck – Soft tissues

PNS

Ideal diagnostics

Ideal diagnostics

x-ray Nasopharynx

Ideal diagnostics

XX--RAY CHESTRAY CHEST

NUTSHELLNUTSHELL::

The Only Diagnostic Investigation nearly The Only Diagnostic Investigation nearly

Needed by all the Medical PractitionersNeeded by all the Medical Practitioners

{ { All Medical SubAll Medical Sub--specialitiesspecialities & Surgical & Surgical SpecialitiesSpecialities as Preas Pre--Operative Operative WorkWork--up} up}

Ideal diagnostics

Ideal diagnostics

Why CXR Important

Two Vital Organs Heart and LungsTwo Vital Organs Heart and Lungs

Ideal diagnostics

Indications for AP View

1.1. Pediatric age GroupPediatric age Group2.2. Bed ridden PatientsBed ridden Patients3.3. Bony [rib] FractureBony [rib] Fracture

Decubitus View for Minimal Pleural Decubitus View for Minimal Pleural effusionseffusions

Ideal diagnostics

X-RAY REPORTING

1.1. TRACHEATRACHEA2.2. CARDIAC CARDIAC

SHILHOUTTESHILHOUTTE3.3. CTRCTR4.4. HILAR REGIONSHILAR REGIONS5.5. COSTO-COSTO-

PHRENIC PHRENIC ANGLESANGLES

6.6. LUNG FIELDSLUNG FIELDS7.7. CHEST WALLCHEST WALL

Ideal diagnostics

Ideal diagnostics

Ideal X-Ray

1.1. Vertebral Column Should be Vertebral Column Should be VisibleVisible

2.2. Equal Sterno-Clavicular distanceEqual Sterno-Clavicular distance

Ideal diagnostics

2 Vital Organs

Ideal diagnostics

Ideal diagnostics

Physiological Variations

Ideal diagnostics

AGE RELATED CHANGES

AORTIC KNUCKLEAORTIC KNUCKLE COSTO-CHONDRAL CALCIFICATIONSCOSTO-CHONDRAL CALCIFICATIONS THYMIC SHADOWTHYMIC SHADOW

Ideal diagnostics

Aortic Knuckle

Ideal diagnostics

Thymus

Ideal diagnostics

Rib Calcifications

Ideal diagnostics

LOBAR & SEGMENTAL ANATOMY

RIGHT LUNGLOBES

[1] UPPER LOBE [a] APICAL [b] ANTERIOR [c] POSTERIOR [2] MIDDLE LOBE [a] MEDIAL [b] LATERAL [3] LOWER [BASAL] LOBE [a] APICAL [b] MEDIAL [c] ANTERIOR [d] LATERAL [e] POSTERIOR FISSURES MAJOR [OBLIQUE] MINOR [ HORIZONTAL]

LEFT LUNGLOBES

[1] UPPER LOBE [a] APICO-POSTERIOR [ b] ANTERIOR [c] SUPERIOR LINGULAR [d] INFERIOR LINGULAR [2] LOWER LOBE [a] APICAL [b] ANTERIOR [c] LATERAL [d] POSTERIOR FISSURES MAJOR FISSURE

Lung Segments

Ideal diagnostics

Appearance of Pathologies

Ideal diagnostics

Lt Pleural Effusion

PLEURAL EFFUSION

Ideal diagnostics

Ideal diagnostics

Raised Diaphragm

Ideal diagnostics

CTR

CARDIAC SHILHOUTTE

BORDERAPEX

Cardiomegaly

Ideal diagnostics

Lung Parenchyma

FOCAL LESIONSCOLLAPSE

CONSOLIDATIONMASS LESIONS

DIFFUSE LESIONSILD

Ideal diagnostics

FOCAL MASS LESIONS

BENIGN CYSTIC LESIONBENIGN SOLID LESION

MALIGNANT

Ideal diagnostics

COLLAPSE

FINDINGS VOLUME REDUCTION AIR REPLACEMENT TYPES ACTIVE [External Communication

Patent] PASSIVE

Ideal diagnostics

CONSOLIDATION

AIR REPLACEMENT BY FLUIDPRESERVATION OF VOLUME

PATENT BRONCHI

Ideal diagnostics

Ideal diagnostics

DIFFUSE LUNG LESIONS

• BRONCHO-PULMONARY :

MULTIPLE FOCAL LESIONS

• INTERSTITIAL LUNG OPACITY :

Ideal diagnostics

MULTI-FOCAL LESIONS

> PATCHY > PATCHY CONSOLIDATIOCONSOLIDATIONSNS

> MILIARY TB> MILIARY TB

> METASTASES> METASTASES

Ideal diagnostics

MASS LESION

MEDIASTINAL / PULMONARYCENTRAL / PERIPHERAL

EXTRA-PULMONARYPLEURAL / CHEST WALL

Lung Mass

Ideal diagnostics

PLEURAL PATHOLOGIESEFFUSION

PNEUMOTHORAXMASS LESION

Ideal diagnostics

Rt Pleural Effusion

Hydro-Pneumothorax

Ideal diagnostics

Ideal diagnostics

CONCLUSION

= PRACTICALLY WE ARE GETTING MIXED OF THE ABOVE SAID FINDINGS

= CHEST X-RAY IS THE ONE DIFFICULT TO INTERPRET IN COMPARED TO CT CHEST

= WE AS RADIOLOGISTS READY TO HELP YOU ATLEAST IN SMALL WAY

Ideal diagnostics

ABDOMEN X- RAY

Supine AP

Erect AP

KUB

ABDOMEN X-RAY

Ideal diagnostics

LEFT RENAL CALCULUS

Ideal diagnostics

LEFT RENAL CALCULUS

Pelvic X- Ray

Ideal diagnostics

Ideal diagnostics

Spinous Pathology

Lumbar Spine Cervical Spine Sacral Spine Dorsal Spine Whole Spine

Ideal diagnostics

Parts of Vertebra

Body Endplates Pedicles Lamina Transverse Process Spinous Process

Ideal diagnostics

Spinal Internal Joints

Facet Joints Disco-vertebral joints

Ideal diagnostics

External Joints

Atlanto-Occipital Joint Costo-vertebral joints Sacro-iliac joints

Ideal diagnostics

Cervical Spine

Typical Vertebrae- Body ; Pedicle; [Vertebral foramen +] Neural arch & Spinous Process

. Atypical Vertebrae- 1. Atlas 2. Axis 3. Long Spinous Process C 7

Ideal diagnostics

Dorsal Spine

12 pairs of ribs Costo-Vertebral Joints Relative Immobility

Ideal diagnostics

Spinal Measurements

Measurements: Vertebral Height Disc space width Spinal Canal diameter Inter-pedicular distance [ Lumbar]

Ideal diagnostics

Sacral Pieces

S1 – S5 C1- C3 [ C 5]

Ideal diagnostics

Normal Cervical Spine

Short Neck Long Neck

Ideal diagnostics

Spondylosis

Ideal diagnostics

Cervical to CoccyxSpinal Curvatures : Lordosis Scoliosis

Ideal diagnostics

Lumbar Spondylosis

Narrow Disc Space Marginal Osteophytes

Ideal diagnostics

LS Spine – AP View Pedicles Inter-Pedicular Distance

Ideal diagnostics

EXTREMITIES { APPENDAGES}

SHOULDER & ARM ELBOW & FOREARM WRIST & HAND HIP JOINT & THIGH KNEE JOINT & LEG ANKLE JOINT & FOOT

Ideal diagnostics

X-Ray Shoulder

Arthritis

Ideal diagnostics

Shoulder Dislocation

Ideal diagnostics

X-Ray Knee Joint

Ideal diagnostics

OA KNEE

Ideal diagnostics

Patellar Fracture

Ideal diagnostics

OA KNEE

Ideal diagnostics

ARTHRITIS KNEE

Ideal diagnostics

Is it Harmful ? X-Ray ; CT Scan & PET CT are harmful “Ionic Radiation” 1 Chest X-Ray Producing 0.01 – 0.15 mGy 1 CT Scan = 10- 20 mGy Accepted Background Radiation is 2.4 mGy/y { 1 dental x-ray = 1 day BG Radiation 1 CXR = 10 days BG Radiation 1 Chest/ AB CT = 2-3 yrs BG Radiation}

Usefulness > harmness

Prior Preparations

For Abdomen & X-Ray KUB Prior 2 days Bowel laxative with empty

Stomach. For Contrast Studies Empty Stomach

ULTRASOUND { USG SCAN} Being used Since 1950 Sound Frequency : 20- 20,000 Hz Ultrasound Probes { Convex; TVS; High

Frequency ; 4 D Probe; endocavitary} B-Mode; M-Mode;CFI;Spectral doppler Piezo-electric Crystals Harmless; easily availability; Cheaper;

Portable ALARA { As low as reasonable acceptable}

Ideal diagnostics

Ultrasound Terminology Echogenicity: [a] Iso-echoic = Same echoes as

Comparative structure [b] Hypo-echoic = Low-echoic = Sonolucent =

Sonopoor= echopoor [c] Hyper-echoic= Echogenic=echodense [d] Mixed echoic [e] Post-acoustic shadow / Post-acoustic

enhancement [f] Anechoic = echo-dropout [g] Valsalva manoeure [h] Compressibility

Ideal diagnostics

ULTRASOUND MACHINE

Ideal diagnostics

Portable USG Machine

Ideal diagnostics

ULTRASOUND PROBES

Ideal diagnostics

Cirrhosis Liver

Ideal diagnostics

Liver Hemangioma

Ideal diagnostics

Liver Abscess

Cholelithiases

Ideal diagnostics

RENAL CALCULUS

Ideal diagnostics

Vesical Calculus

Ideal diagnostics

Intra-vesical Ureterocele

Ideal diagnostics

PROSTATOMEGALY

BPH Vs CA

Ideal diagnostics

Catheter in Bladder

Ideal diagnostics

USG SCAN

Appendicitis

UTERINE FIBROIDS

Ideal diagnostics

Endometrial Hyperplasia

PCOD

Ovarian Cyst

Ideal diagnostics

Worm Infestation

Small Parts Scan Thyroid Pathologies Thyroiditis Solitary Nodule MNG Mass Lesion

Small Parts ScanBREAST { Sono-mammogram} Fibro-adenosis Fibro-adenoma Abscess Malignancy

Breast Malignancy

Small Parts Scan Scrotum: Hydrocele Varicocele Torsion Epididymo-Orchitis Mass lesion

Ideal diagnostics

Scrotal Varicocele

Valsalva Resting

Doppler Scan To Find-out Vascular Pathology { either

arterial / Venous} Color Flow Imaging / Spectral Doppler PSV ; EDV ; STENOSIS % DVT Varicose Veins

Arterial Stenosis

3 D/ 4 D SCAN

Prior Preparation

Overnight Fasting

Full Bladder

Menses – not a contraindication for scanning

Lower limb doppler – Concerned dresses

Ideal diagnostics

1. SPIRAL CT SCAN2. MULTI- SLICE CT { single, 4 slice, 16 slice, 64

slice, 128 slice }3. CARDIAC CT4. MAIN USEFULNESS IN HEAD: NECK:

CHEST: ABDOMEN: EATREMITIES

CT SCAN HISTORY

CT SCAN TERMINOLOGY

Hounsfield units Density { iso ; hypo & Hyper} Plain { NECT} & Contrast { CECT} Contrast Dye : Ionic { Urovideo} Non-ionic { Iohexol}

Ideal diagnostics

CT SCAN CONSOLE

Ideal diagnostics

CT SCAN HEAD { Brain}

Ideal diagnostics

CT BRAIN { Plain }

Ideal diagnostics

CT { Plain & Contrast } NECT & CECT

Ideal diagnostics

X-RAY Vs CT

• EXPOSURE• TIMING• PREPARATION• AVIALABILITY• MOBILITY• BASIC INVESTIGATION IN

RADILOGY

Ideal diagnostics

MRI TERMINOLOGY

Intensity { iso ; hyper & hypo}MAGNETS { Superconducting}TESLA UNITS { 0.2 – 3.0 T}

COILSCLAUSTROPHOBIA

PACEMAKER; IMPLANTS INCOMPATIBLECOSTLIER

MRA ; MRS ; FUNCTIONAL MRI

Ideal diagnostics

MRI SCAN

MRI SCAN MAGNETS: Superconducting magnet Units : Tesla { 0.2 to 3.0 T} T1 ; T2 ; FLAIR ; MRS ; MRA ; f MRI Contraindicated : Pacemaker ; Cochlear

implants Claustrophobia

Ideal diagnostics

MRI BRAIN { Plain & Contrast }

MRI Spine

Ideal diagnostics

PET CT SCAN

Combined CT Scan & SPECT Scan

Functional characters assessed

Costlier

Mainly used in Cancer Follow-ups

Ideal diagnostics

PET SCAN BRAIN

Ideal diagnostics

Wholebody Pet Scan

Ideal diagnostics

PET BRAIN

Therapeutic Radiology Drainage of Abscess or collection Guided FNAC Selective Reduction in Twins Angioplasty with Stent Coiling or Glue apply in Aneurysm

Ideal diagnostics

60 yrs old Post menopausal woman with C/O Bleeding PV

Clinical exam; Speculum examination Next ..

Ideal diagnostics

Case Scenario : 3

Ultrasound Scan Pelvis Bulky Uterus Fibroid with

Endometrial Thickening

Post menopausal EM- > 4 mm

HPE

Ideal diagnostics

MRI PELVIS Extent of EM

EM- Myometrial distinction

Parametrial invasion

Local MetastasesIdeal diagnostics

Case Scenario : 4 30 yrs female with Colicky abdominal Pain in

Right sided abdomen ? Ureteric Colic ? Appendix ? Ovarian ?? Cholelithiases Symptomatic Tx.

Ideal diagnostics

USG ABDOMEN Renal

Hydronephrosis Ureter is dilated Not traceable

Ideal diagnostics

X-Ray KUB Size & Site of

Calculus Number of Calculus Radiolucent ?

Ideal diagnostics

SPIRAL CT SCAN KUB Exact size & site Asso. Complications

Ideal diagnostics

Case Scenario: 5 Middle aged male with fever; Chronic

Cough; loss of appetite ; loss of weight High ESR ; Raised Lymphocytes

Ideal diagnostics

CHEST X-RAY PA VIEW

Ideal diagnostics

Ideal diagnostics

Topic Specific

PCOD

Enlarged Ovaries Peripherally arranged

Small cystic structures Central cyst free

stroma

EM Thickening

Fibroid Uterus Common in Middle

aged females Nulliparous 3 Types SM –type = Bleeding Major decision upto

Menopause

Ovarian Cyst

Benign Vs Malignant

Functional

Fibro-adenoma Breast

Fibroadenosis Vs Fibroadenoma Vs Ca Quadrants Clock Positions Sonomammogram Vs X-Ray mammogram

Follicular Study { Ovulation } Basal Scan on 2nd Day

of menses Next Scan On 10th day Follicle matures at a

rate of 1-2 mm / day Maximum size

expectation 20-25 mm Size reduction with FF

& em thickening HSG Next

Calculous Disease Urolithiases :

4 Types calculi

Common sites of Ureteric narrowings – PU Jn; iliac vessel crossing; Pelvic brim;VU Jn

GB Calculi

2 Types:

Mobile / fixed

Obstructed / Non obstructed

Asso. Cholecystitis

Thyroid

Thyroiditis

Solitary nodule MNG

CA Thyroid

FNAC

Feedback 1] Common Chest X-Ray View ?

2] Term used in CT & MRI ?

3] USG Scan harmful ?

4] Koch’s Preferred site in Lung ?

5] Shoulder pain next to X-Ray what ?

Takehome message… Please use Diagnostic modalities to arrive at a

Proper diagnosis before Start of treatment Common X-Rays are: Chest X-Ray PA View X-Ray PNS for Sinuses X-Ray Spine AP & Lateral Views for Backache

. USG Scan abdomen for Renal Calculus / Uterine Fibroids

Takehome message… HRCT Scan for Head & Chest HFU Scan for Thyroid ; Breast ; Scrotum and

any swelling MRI Scan for Head; Neck ; Spine & Joints PET Scan for Activity of the lesion and whole

body Spread If any doubt, please don’t hesitate to call me 94472 77746

Significance of RADIOLOGY Ever expanding , Fascinating diagnostic

Modality Proper & Judicious use of Radiology for

arrive at a diagnosis DON’T Lag behind your allopathic

Colleagues Keep update yourself