1
Q
How is visual acuity tested?
A
- Rosembam (14in) & Snell chart (20ft)
- Do not press eye when do one eye at a time
2
Q
How is visual acuity interpretated?
A
- 20/20 vision: individual tested sees at 20ft what normal eye sees at 20ft (normal vision)
- 20/200 vision: individual sees at 20dt what normal eye sees at 200 ft (impaired vision)
- 20/10 vision: individual tested sees at 20ft, what a normal eye sees at 10ft (better than normal)
3
Q
How is color vision tested?
A
- Ishihara color blindness test vs. red/green identification
4
Q
What is noted during ocular motility testing?
A
- Speed, smoothness, range, symmetry of movement, watch for nystagmus
5
Q
When would we check visual acuity, color vision, visual field testing, ocular motility testing, and pupillary responses (pupillary reflex, corneal light reflex, accommodation)?
A
- Vision screening (esp 5yro, sports physical, not included 25-50yro unless sx - over 65yro yearly)
- Eye injury
- Suspected deficit
- Trauma
- Stroke
- Pt sx (visual blurring, diplopia, reduced visual field)
6
Q
What is tonometry?
A
- Dx test measuring intraocular pressure
- Applanation (contact: force needed to flatten cornea estimate intraocular pressure - part of slit-lamp or hand-held
- Non-contact: uses same principle as applanation but w/ puff of air instead.
- Force of air returning from cornea measured & intraocular pressure estimated
- Use: dx/screening/managing ocular HTN & glaucoma
- Glaucoma: repeated elevated pressure w/ systemic symptoms
- Normal: 10-21mmHg
- If elevated perform visual field testing before tx
7
Q
What is the slit lamp exam?
A
- Microscope projecting focused light beam helping to examine anterior segment of eye (Posterior segment visualized w/ special lenses)
8
Q
What is fluorescein staining?
A
- Brightly fluorescent organic dye that appears bright green in cobalt blue light (lights up water based/water soluble)
- Dx: corneal ulcers & abrasions, herpetic keratitis, FB
- If epithelium of cornea not intact for any reason, aqueous humor seeps through & miz w/ fluorescein
- Superficially: fluoresceine impregnated strip applied to anterior eye
- Can also be used IV to stain blood vessels of retina & iris
9
Q
What is the seidel test?
A
- Specific type of fluoresceine test
- Assess presence of large amount of aqueous humor from anterior chamber
- Can indicate following: large corneal effect, large scleral defect
- Positive: aka corneal waterfall sign
- Indicated by Visible corneal defect
10
Q
How is vision screening conducted in newborns to 6mo?
A
- Vision assessment (fixate & follow response): usually able by 6-8wks
- refer to optho if unable to fix & follow by 3mo
- External eye examination
- Pupillary response
- Simultaneous & bilateral “red” reflex/fundus reflex
- Darker skinned babies can have bluish or yellowish tint
- If white appearance can indicate retinoblastoma (tumor b/w retinal & cornea)
11
Q
How is vision screening conducted in 6-12mo?
A
- External eye exam, pupillary response, simultaneous & bilateral red reflex + ocular motility
12
Q
How is vision screening conducted 1-3yr?
A
- fix & follow or older cooperative toddlers LEA optotypes
- Do not make snap decisions b/c based on cooperation. Do again another day .
- external eye exam, pupillary response, simultaneous & bilateral red reflex + ocular motility
- Instrument based vision screening (autorefraction etc) if available (age where child can sit still)
- Ophthalmoscopy if possible
13
Q
How is vision screening conducted in 4-5yrs+?
A
- fix & follow or LEA optotypes
- external eye exam, pupillary response, simultaneous & bilateral red reflex + ocular motility
- Instrument based vision screening (autorefraction etc) if available
- Ophthalmoscopy
- Ocular alignment (cover-uncover test)
- Monocular visual acuity w/ Snellen chart or pictures (E chart)
- Don’t make too many snap decisions
- if use pictures let pt name symbols before test
14
Q
When should a patient be referred to the ophthalmologist?
A
- Abnormal red reflex
- Personal hx of prematurity (risk factor for ocular conditions)
- FH of dz like retinoblastoma or childhood glaucoma
- Pupillary asymmetry (may be normal but do not assume risk yourself)
- Unilateral or bilateral ptosis
- Nystagmus
15
Q
What are audiograms?
A
- Visual result of audiometry, test measuring pt’s response different intensities & frequencies of sounds
- X-axis: frequency (pitch) of a sound: thunder to whistles (L to R)
- Y-axis: intensity (loudness) of sound: whispers to jackhammers (top to bottom)
(O is right, X is left)
16
Q
How is an audiogram done?
A
- Audiologists plays pure tone (or sound w/ single frequency)
- Pt signals when they hear the sound
- Hearing threshold = softest sound person can hear 50% of the time
- R & L ear tested separately in quiet environment w/ pt wearing headphones & bone conductor (usually air conduction only)
17
Q
What does sensorineural healing loss look like on an audiogram?
A
- Read is lower on Y axis and lower as go to right of X axis
- Can’t hear soft sounds or high pitches
- Mild if start in normal range becomes moderate if extend low
18
Q
What does conductive hearing loss look like on an audiogram?
A
- Read is lower on Y axis consistently
- Can’t hear soft sounds (only)
19
Q
What is the dix-hallpike maneuver?
A
- Dx: Benign paroxysmal positional vertigo - movement (BPPV)
- Procedure: Sitting w/ head turned 45 degrees, patient leans back w/ one ear pointed to ground stay for 1-2min & check eyes for nystagmus
- Inner ear d/o caused by Ca debris floating in endolymph of semicircular canals & putting pressure on hair cells, which causes nausea & vertigo
- Positive: nystagmus in direction of gravity when pt’s head turned to affected side (vertigo & nausea will usually be elicited)
(Epley maneuver used for TX)
20
Q
What is tympanometry?
A
QA- Test evaluates proper functioning of middle ear by measuring movement & flexibility of eardrum in response to changes in pressure
- Type A: normal tympanogram/ sensorineural hearing loss where conductive mechanism is normal (peak in middle of pressure change)
- Type B: Flat curve, no change in compliance w/ pressure changes. Seen in fluid in middle ear (otitis media)
- Type C: Maximum compliance in negative pressure. Seen in eustachian tube obstruction (peak shifted with negative pressure)
21
Q
What is nasolaryngoscopy?
A
- Procedure w/ small, lighted camera on flexible scop passed through nose & into throat. Topical anesthesia of nasal passages may be used
- Anatomy examined: nasal cavity, posterior nasal space (including Eustachian tubes), base of tongue, Epiglottis, larynx (including vocal cords)
- Indications: removal easily accessible FB, evaluation of obstructive sleep apnea, fiber endoscopic evaluation of swallowing, vocal cord injections for palsies
- CI: epiglottitis, croup
- Dx: nasal septal deviation & perforations, nasal mucosal edema, nasal polyps, epiglottis abnormalities, persistence of tonsillar & lymphoid tissue into adulthood, eustachian tube abnormalities
22
Q
What is the rapid strep test?
A
1- result w/i min Ag or nucleic acid detection test that is used at point of care to assist in Dx bacterial pharyngitis caused by GAS. If negative test & high clinical suspicion a rapid test can be confirmed w/ throat culture
- Procedure: pt open mouth widely, visualize tonsils/tonsillar pillars, helpful to depress tongue if possible, swab entire back of throat & follow kit instruction to obtain result
- Sen/spec: rapid ag detection 85%/95%, nucleic acid detection test 92%/99%
- Negative w/ high clinical suspicion -> culture
23
Q
What is the rapid mono test?
A
- POC using latex agglutination determine whether Ab to EBV present in pt’s blood
- Procedure: obtain serum sample or fingerstick blood sample, follow kit instructions
- Sensitivity/specificity varies; sen poor pt <4yro, Spec 95-100%
24
Q
What is the nasopharyngeal swab?
A
- POC mainly for influenza & cold but nasal swabs available for both w/ similar sensitivity & specificity
25
What imaging would you like to order for your patient presenting with congestion and facial pain/pressure?
Sinusitis suspected
- CT scanning: choice for chronic sinusitis evaluation, usually not indicated for acute sinusitis (MRI over dx sinus dz)
- XR: **Not indicated** for sinusitis
26
You suspect that your patient has a neck mass, what imaging would you perform?
- US: differentiate neck masses (lymph nodes vs cyst vs abscess)
27
What imaging would you order to assess eye injuries?
can perform POCUS for eye injuries but requires skill
28
You suspect skull pathology in your patient, what imaging do you order?
XR
29
You suspect a facial fracture, what imaging do you order for your patient?
- XR: orbital & facial fractures
- CT w/o contrast best for temporal bone fracture
- MRI: orbit
30
What patient scenarios suggest MRI?
- Orbit, MR angiography neck, TMJ, acoustic neuroma
31
What is allergic rhinitis?
- Atopic dz w/ sx sneezing, nasal congestion, clear rhinorrhea & nasal pruritis
- IgE-mediated immune response against inhaled Ag w/ subsequent leukotriene-mediated late phase
32
What is in Vivo allergy testing?
- Skin testing w/ suspected allergens
- Transdermal administration of dilute solutions containing Ag elicits "wheal & flare" response in sensitized individual
- Patch vs prick testing
- Positive skin test + H&P indicative of allergy = allergen causing pt sx
- Advantages: quick, simple, low cost, **more sensitive**
33
What is in vitro allergy testing?
- Quantitative assays of allergen specific IgE in blood
- 70-80% correlation w/ skin testing to pollen, dust mites, danders
- Skin testing still best
- Advantages: can be used in pt on antihistamines or w/ dermatitis
- May be mor predictive of food allergies
34
You suspect an abdominal emergency (non-traumatic) what imaging is indicated?
1. US
2. CT (if US inconclusive)
3. MRI (alt to CT in select cases - especially in children/young pts)
35
You suspect that your trauma patient has an abdominal emergency. What imaging is warranted?
Low-energy trauma limited to abdomen:
1. US (FAST - hemoperitoneum esp in unstable pts)
2. CEUS (improves US sensitivity in detecting parenchymal trauma & active hemorrhage)
High energy trauma:
.1. CT
36
Your patient exhibits jaundice, what imaging is indicated?
1. US: confirm obstructive cause by bile duct dilation
2. MRI: if US inconclusive
3. CT: if MRI unabailable, low sensitivity for bile duct calculi
37
Your patient has urinary symptoms, what imaging studies may be indicated?
1. US: confirm presence of hydronephrosis
.1. CT: dx renal/ureteral calculi
38
Your patient has an abdominal palpable abnormality, what imaging is indicated?
.1. US: hepato/spenomegaly. & exclude abdominal mass to avoid radiation
.1. CT: characterizing abdominal mass discovered by PE/US
.2. MRI: CT substitute in selected cases
.1. MRI: characterizing pelvic masses
39
Your patient has elevated liver enzymes, what imaging may be warranted?
1. US: dx & characterizing diffuse liver dz
2. MRI: complementary to US - quantify diffuse liver dz
40
Your patient has an oncotic disease. What imaging is used to stage and evaluate it?
1. CT: baseline imaging & F/U
2. MRI CT complement for characterization of indeterminate lesions (esp focal liver lesions)
.2. CEUS: characterization indeterminate liver lesions seen on CT
41
You suspect a congenital abnormality in your patient. What imaging is indicated?
.1. US: ante- & postnatal
.2. MRI: better characterization of abnormalities, incompletely evaluated by US (both ante& post-natal use)
.1. CT: complex urinary tract malformations
42
Your patient is here for a transplant or is following up after a transplant for an evaluation. What imaging is indicated?
1. CT: suitable to assess vascular structures
2. US: F/U to avoid radiation
3. CEUS: improves US sensitivity depicting vascular complications in transplanted pt
43
You need imaging to guide an interventional procedure, what imaging is indicated?
1. US
2. CEUS: improve US guided procedures
2. CT: when US cannot guide procedure (US not identify lesion or vascular/digestive interpositions)
44
You want to evaluate for postoperative complications. What imaging is indicated?
1. US
2. CT: characterizations of abnormalities discovered by ultrasound
45
What is the imaging for the F/U of liver cirrhosis/characterization of liver nodules in liver cirrhotic?
1. US
2. CEUS/CT/MRI: characterization of nodules found by US
46
What imaging is indicated for the evaluation of abdominal vessels?
1. CT: for abdominal aortic aneurysm (characterization & F/U)
2. US: F/U ectatic abdominal aorta to avoid over irradiation
47
What imaging is indicated for characterization of incidentally discovered focal liver lesions?
1. CEUS: in experienced centers
2. MRI: for inconclusive CEUS findings
3. CT: when MRI not possible
48
You suspect your patient has a liver infection. What imaging is indicated?
1. US: liver abscess or hydatid cyst
2. CEUS/CT/MRI: differentiate between infectious lesions & focal liver lesions
49
What imaging is indicated for the evaluation of pancreatic tumors?
1. CT
2. US: endoscopic complementary to CT
3. MRI: clarify inconclusive findings
50
What imaging is indicated by inflammatory bowel disease?
1. US & MRI complementary roles in evaluation & F/U
2. CT substitute for MRI
51
What imaging is used for local staging of rectal tumors?
1. MRI
2. US: endoscopic complementary to MRI
52
What is the imaging for perianal fistulas?
MRI
53
What options are available to visualize the organs of the abdomen?
- Plain XR
- Barium enhanced radiographs & fluoroscopy
- CT (including colonography)
- MRI
- Nuclear medicine scans
- US
54
What are the indications for a plain film of the abdomen?
- Bowel gas in emergent setting
- Evaluation of lines and tubes: *NG, drain placement, G tube, JPEG*
- FB (esp kids)
- Free air (before/after procedure)
- Passage of contrast through bowel (GI motility issue)
- Monitoring renal calculi (where, movement, number - only Ca visible (other: urea))
- "First step" before ordering other imaging, or as F/U
55
What are the anatomical landmarks of plain XRs?
- Liver border
- Psoas shadows (diagonal lines)
- Renal contours
- Bowel gas
- Bony structures
56
What is the method to reading an abdominal XR?
1. Overall gas pattern
- Distended: completely full of air
- Dilated: beyond normal size
- Small bowel (valvulae conniventes): normal diameter <2.5cm, air in 2-3loops
- Large bowel (has haustra): almost always air in rectum/sigmoid
- Stomach: almost always air fluid level in stomach in upright film
2. Extraluminal air
3. Abnormal calcifications
4. Soft tissue masses
57
What are the difference between normal and pathologic calcifications?
- Phleboliths: normal - small **rounded** calcifications which are usually **calcified venous thrombi**, usually occur in pelvic veins, have a **lucent center** (**Kidney, bladder & ureteral stones do not often have a lucent center**)
- Urolithiasis: small opaque
- Uterine fibroids: larger & multiple rounded semi-opaque (better seen US)
- Appendicolith: large in appendix area
58
What are the differences between normal and abnormal intestinal gas patterns?
- Adynamic ileus: *failure of passage of enteric contents through small bowel & colon not mechanically obstructed (paralysis)*
- Generalized gaseous distention of large & small bowel
- Small (80%) and large (20%) bowel obstruction *ex/intrinsic - adhesions, masses, inflammation, Crohn's*
- Dilated loops of bowel proximal to obstruction (Small - just see small, large - see both)
- Air/fluid levels in same loop of bowel but different heights
- String-of-beads sign (*small pockets of gas w/i fluid filled bowel*)
- Sigmoid volvulus: *sigmoid colon twists on mesentery = LBO, 60% intestinal volvus involve sigmoid, cecum also common*
- Wall not have haustra, "Coffee bean" sign - closed loop
- Pneumoperitoneum: *gas w/i peritoneal space, MC cause bowel perforation, also pneumothorax/mechanical ventilation. best XR is CXR, can be detected on abdominal XR, CT more sensitive*
59
What does stool look like on an abdominal XR?
- lacy appearance
60
What are the indications for esophagram?
- Upper GI (aka barium swallow/esophagram)
- Visualise: forms & motility of esophagus, stomach, duodenum, upper jejuneum
- Dx: hiatal hernia, pyloric stenosis, polyps
- Contrast: usually barium
(modified barium swallow helpful for evaluating swallowing d/o)
61
What are the indications for upper GI with small bowel follow through?
- Visualize: forma & motility small bowel (typically w/ UGI)
- Commonly dx: ulcerative colitis, tumors, intussusception, **obstruction**
- Contrast: usually barium
62
What are the indications for barium enema?
- Visualizes: form & motility large intestine (colon) and rectum
- Commonly dx: lesions, **obstructions**, fistulas, diverticula, stenosis, polyps, intussusception
- Contrast: usually barium (instilled into large intestine through rectal tube)
- Appendix size & position can be evaluated but XR not dx acute appendicitis
63
What are the indications for video fluoroscopic swallowing studies?
"Swallowing study"
- Repeated pneumonia, neuro dx
- High risk or signs of aspiration
- Inc work of breathing with eating
- Chronic cough or visible choking
- Throat clearing hoarseness
(pharynx & larynx function)
64
What are the CI to barium?
- Complete bowel obstruction (gastrograffin instead) (has not has bowel movement in long time + PE gastric distention & pain = high risk of perforation)
- Suspected perforation
- Paralytic ileus
- Recent abdominal surgery
- H/o anaphylaxis or severe allergy with barium
65
What are the CI to IV contrast?
- Renal failure (serum Cr >1.5mg/dL)
- Previous allergy
- Pregnancy
- thyrotoxicosis
- Diabetic taking metformin (stop metformin 24-48hrs prior)
66
What is the used of a contrast?
- Good:
- Relatively harmless
- Does not interfere with physiologic function
- Moderate cost
- Radiopaque vs radiolucent
- Oral, rectal, IV/injection
- **be alert to possibility of reaction, still cause death ~1/20-40k administrations)
- Most water soluble
67
What are the indications for CT with bowel contrast?
(Rectal contrast)
- Suspected penetrating colonic injury
- Possibly appendicitis
- Note: not always reach proximal small bowel & appendix so some centers give oral contrast but there is a delay
68
What are the indications for CT with IV contrast?
- Evaluation of infxn & inflammation: diverticulitis, evolving pancreatitis, pyelonephritis
- CA staging
- Evaluation vascular abnormalities: GI bleeds, aortic dissection/aneurysm
69
What are the indications for CT w/o contrast?
- Bowel perforations (risk for spilling into peritoneum)
- kidney stones (not needed)
- hematoma
70
What are the indications for CT colonography?
- AKA "virtual colonoscopy"
- not quite as good as direct colonoscopy
- CT generated images reconstructed give 3D images of interior of the colon (usually only seen with endoscope)
- Indications: Colon CA screening (ACS recommend once every 5yrs)
71
What are the indications for CT angiography?
**Vascular pathology**
- Aneurysm
- Thrombosis
- Stenosis (renal)
- Dissection
- Vasculitis
- Bowel ischemia
72
What are the indications for MRCP?
MRI/MR cholangiopancreatography
T2 weighted sequences of MRI to look at intra & extrahepatic biliary tree & pancreatic ductal system **anatomy**
- Evaluating possible congenital abnormalities
- Biliary strictures
- Chronic pancreatitis
- Pancreatic cystic lesions
73
What are the indications for HIDA?
- Hepatobiliary IminoDiacetic Acid (the radioactive tracer used)
- Aka cholescintigraphy
- Anatomy **& function** of biliary system
- Show bile ejection help determine if gallbladder should be removed
- Indications:
- Acute cholecystitis
- Biliary atresia in neonates
- Suspected bile leak
- Biliary obstruction
- Sphincter of Oddi dysfunction
74
What are the indications for gastric emptying study?
- Aka gastic scintigraphy
- Radiotracers for evaluation of anatomy & function of stomach
- Indication: suspected gastroparesis
(DM pt has stomach pain, N/V)
75
What are the indications for Meckel's scan?
- Meckel diverticulum: congenital intestinal diverticulum due to fibrous degeneration of umbilical end of omphalomesenteric (vitelline) duct occurs around distal ileum
- Can lead to:
- GI hemorrhage, small bowel obstruction, volvulus, intussusception, Meckel diverticulitis, perforation, neoplasm
- Nuclear imaging: should be smooth continuation (normal) but instead has abnormal spot where radiotracer hangs out
76
What are the indications for RBC-tagged scan?
- AKA GI bleeding scan (GIBS)
- Indications:
- ID source of obscure bleed
- Assist in angiography
(see abnormal blips of radiotracer)
very useful!
77
Thoughts to guide general GI imaging
- Mild obstructive sx: treat based on hx & PE alone
- Severe obstructive sx (not passing anything, acute, long time): CT (if not an option - XR)
- Suspected perforation: long time obstruction, recent surgery - XR look for pneumoperitoneum (NO barium)
- Upper GI for things like GERD
AAA PA: Lab & Diagnostic Testing
flashcards
Decks in class (15)
# Cards
-
Module 1a: Intro, BMP, CMP36
-
Module 1b: CBC, UA, Derm48
-
Module 2: Radiology & Neuroimaging/diagnostics122
-
Module 3: Musculoskeletal73
-
Module I: Behavioral48
-
Module 2a: Cardiac Labs28
-
Module 2b: Electrocardiogram63
-
Module 2c: Electrocardiogram54
-
Module 2d: Cardiopulmonary Imaging & Advanced Cardiac Evaluation89
-
Module 3: Endocrinology, Pulmonology139
-
Module 1: EENT & Abdominal Imaging77
-
Module 2: GI Imaging & Labs109
-
Module 3: GU & Renal67
-
Module 4: Electrolytes & Fluids40
-
Module 5: Hematology & ID35
