VEL TECH MULTI TECH Dr.RANGARAJAN Dr.

SAKUNTHALA ENGINEERING COLLEGE

(Approved by AICTE, New Delhi & Affiliated to Anna University, Chennai) No.60, Avadi Vel Tech Road, Chennai 600 062.

BM2356- HOSPITAL TRAINING LAB

NAME : M.CHITRA ROLL NO. : VM4813 REGISTER NO : 11809121004 BRANCH : BIOMEDICAL ENGINEERING YEAR : IV year

VEL TECH MULTI TECH Dr.RANGARAJAN Dr.SAKUNTHALA ENGINEERING COLLEGE

(Approved by AICTE, New Delhi & Affiliated to Anna University, Chennai) No.60,Avadi Vel Tech Road, Chennai 600 062.

Name M.CHITRA Year IV Semester VII Branch BIOMEDICAL ENGINEERING University Register No11809121004 College Roll No VM4813 Certified that this is the bonafide record of work done by the above student in the Hospital Training Lab (BM2405) during the academic year 2012-2013

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Signature of HOD Signature of Lab Incharge ________________________________________________________________ Submitted for the University Practical Exam held on at VEL
TECH MULTI TECH Dr.RANGARAJAN Dr.SAKUNTHALA ENGINEERING COLLEGE,#60,AVADI VEL TECH ROAD,CHENNAI 62.

Signature of Examiners Internal: . External: . Date:

HOSPITAL TRAINING
Venue :
Rohini Multi Speciality Hospital, Near Manimandapam, Tanjore, Thanjavur-613007

Date of visit : 13th August 2012 to 17th August 2012.

Departments in hospital

Intensive care unit(ICU) Dialysis center Computed Tomography(CT) Magnetic Resonance Imaging(MRI) X-Ray Echocardiogram and TMT Electromyography (EMG) Electroencephalogram(EEG)

Electrocardiogram(ECG)

Ultrasonography

ROHINI MULTI SPECIALITY HOSPITAL, THANJAVUR

HISTORY :
Rohini multi speciality hospital is located in thanjavur .Rohini hospital are among the topnotch hospitals in Thanjavur ISO 9001 : 2000 Certified Hospital . They are known to provide medical and therapeutic services. In the year 2006-07, about 5864 major and 3747 minor surgeries took place in Rohini multi speciality hospital,thanjavur.. Trauma cases account for 90 percent of the inpatient admission daily in the hospital. It is located in thanjavur near Manimandapam which is one of the famous tourist spot. The Managing Director of Rohini hospital is Dr.R.Rathina Sabapathy M.s.,Orth,DOrth.Cons.Ortho Surgen . Constructed at a cost of Rs. 38 crore, the buildings include a 300-bed hospital, provisions for the functioning of all specialty departments, out-patient ward, laboratory buildings, etc. Hospital super-specialty departments are Neuro Surgery, Neurology, Urology, Nephrology, Medical Gastroenterology, Surgical Gastroenterology, Thoracic Medicine, Oto-Rhino-Laryngology (ENT), Cardiology, gynaecology , paediatrics, Cardio Thoracic Medicine, casualty block, laboratories and all outpatient wards.

1. INTENSIVE CARE UNIT(ICU)

Intensive care unit (ICU) equipment includes patient monitoring, respiratory and cardiac support, pain management , emergency resuscitation devices, and other life support equipment designed to care for patients who are seriously injured, have a critical or life-threatening illness, or have undergone a major surgical procedure, thereby requiring 24-hour care and monitoring.

PURPOSE :
An ICU may be designed and equipped to provide care to patients with a range of conditions, or it may be designed and equipped to provide specialized care to patients with specific conditions. For example, a neuromedical ICU cares for patients with acute conditions involving the nervous system or patients who have just had neurosurgical procedures and require equipment for monitoring and assessing the brain and spinal cord. A neonatal ICU is designed and equipped to care for infants who are ill, born prematurely, or have a condition requiring constant monitoring. A trauma/burn ICU provides specialized injury and wound care for patients involved in auto accidents and patients who have gunshot injuries or burns.

DESCRIPTION:
Intensive care unit equipment includes patient monitoring, life support and emergency resuscitation devices, and diagnostic devices.

Patient monitoring equipment :

Patient monitoring equipment includes the following: Multiparameter monitoring systemcomprehensive patient monitoring systems that can be configured to continuously measure and display a number of parameters via electrodes and sensors that are connected to the patient. These may include the electrical activity of the heart via an EKG, respiration rate (breathing), blood pressure, body temperature, cardiac output, and amount of oxygen and carbon dioxide in the blood. Each patient bed in an ICU has a multiparameter monitor that measure these body activities. All monitors are networked to a central nurses' station. These lightweight parameter patient monitors and compact multiparameter patient monitor are used to monitor different body conditions of patients like heart beat, ECG, pulse oxygen saturation, noninvasive blood pressure and respiration. Further, these portable patient monitor are capable of working on both alterative current as well as direct current.

Pulse oximetermonitors the arterial hemoglobin oxygen saturation (oxygen level) of the patient's blood with a sensor clipped over the finger or toe

LIFE SUPPORT AND EMERGENCY RESUSCITATIVE EQUIPMENT :

Intensive care equipment for life support and emergency resuscitation includes the following: Ventilator (also called a respirator)assists with or controls pulmonary ventilation in patients who cannot breathe on their own. Ventilators consist of a flexible breathing circuit, gas supply, heating/humidification mechanism, monitors, and alarms. They are microprocessor-controlled and programmable, and regulate the volume, pressure, and flow of patient respiration. Ventilator monitors and alarms may interface with a central monitoring system or information system.

Infusion pumpdevice that delivers fluids intravenously or epidurally through a catheter. Infusion pumps employ automatic, programmable pumping mechanisms to deliver continuous anesthesia, drugs, and blood infusions to the patient. The pump is hung on an intravenous pole placed next to the patient's bed.

DefibrillatorA defibrillator is a machine used to shock the victim's heart and restore the heart's normal rythmic patterns. When a defibrillator is used, it in effect kicks the heart into action again, causing it to resume sending blood throughout the body.

DIAGNOSTIC EQUIPMENT:
The use of diagnostic equipment is also required in the ICU. Mobile x-ray units are used for bedside radiography, particularly of the chest. Mobile x-ray units use a battery-operated generator that powers an x-ray tube. Handheld, portable clinical laboratory devices, or point-of-care. Analyzers, are used for blood analysis at the bedside. A small amount of whole blood is required, and blood chemistry parameters can be provided much faster than if samples were sent to the central laboratory.

OTHER ICU EQUIPMENT:

GlucometerA glucose meter (or glucometer) is a medical device for determining the approximate concentration of glucose in the blood. It is a key element of home blood glucose monitoring (HBGM) by people with diabetes mellitus or hypoglycemia. A small drop of blood, obtained by pricking the skin with a lancet, is placed on a disposable test strip that the meter reads and uses to calculate the blood glucose level. The meter then displays the level in mg/dl or mmol/l.

Laryngoscopy Laryngoscopy (larynx + scopy) is a medical procedure that is used to obtain a view of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation or for procedures on the larynx or other parts of the upper tracheobronchial tree.

Arterial Blood Gas(ABG) An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in the groin or other sites are used. The blood can also be drawn from an arterial catheter

Pulse oximetry plus transcutaneous carbon dioxide measurement is an alternative method of obtaining similar information as well. An ABG is a test that measures the arterial oxygen tension (PaO2), carbon dioxide tension (PaCO2), and acidity (pH). In addition, arterial oxyhemoglobin saturation (SaO2) can be determined. Such information is vital when caring for patients with critical illness or respiratory disease. As a result, the ABG is one of the most common tests performed on patients in intensive care units (ICUs).The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to determine gas exchange which reflect gas exchange across the alveolar-capillary membrane. ABG testing also has a variety of applications in other areas of medicine.

Disposable ICU equipment includes urinary (Foley) catheters, catheters used for arterial and central venous lines, Swan-Ganz catheters, chest and endotracheal tubes, gastrointestinal and nasogastric feeding tubes, and monitoring electrodes. Some patients may be wearing a posey vest, also called a Houdini jacket for safety; the purpose is to keep the patient stationary. Spenco boots are padded support devices made of lamb's wool to position the feet and ankles of the patient. Support hose may also be placed on the patient's legs to support the leg muscles and aid circulation.

OPERATION :
The ICU is a demanding environment due to the critical condition of patients and the variety of equipment necessary to support and monitor patients. Therefore, when operating ICU equipment, staff should pay attention to the types of devices and the variations between different models of the same type of device so they do not make an error in operation or adjustment.

Although many hospitals make an effort to standardize equipmentfor example, using the same manufacturer's infusion pumps or patient monitoring systems, older devices and nonstandardized equipment may still be used, particularly when the ICU is busy. Clinical staff should be sure to check all devices and settings to ensure patient safety. Intensive care unit patient monitoring systems are equipped with alarms that sound when the patient's vital signs deterioratefor instance, when breathing stops, blood pressure is too high or too low, or when heart rate is too fast or too slow. Usually, all patient monitors connect to a central nurses' station for easy supervision. Staff at the ICU should ensure that all alarms are functioning properly and that the central station is staffed at all times. For reusable patient care equipment, clinical staff make certain to properly disinfect and sterilize devices that have contact with patients. Disposable items, such as catheters and needles, should be disposed of in a properly labeled container.

MAINTENANCE :
Since ICU equipment is used continuously on critically ill patients, it is essential that equipment be properly maintained, particularly devices that are used for life support and resuscitation. Staff in the ICU should perform daily checks on equipment and inform biomedical engineering staff when equipment needs maintenance, repair, or replacement. For mechanically complex devices, service and preventive maintenance contracts are available from the manufacturer or thirdparty servicing companies, and should be kept current at all times.

HEALTH CARE TEAM ROLES:

Equipment in the ICU is used by a team specialized in their use. The team usually comprises a critical care attending physician (also called an intensivist), critical care nurses, an infectious disease team, critical care respiratory therapists, pharmacologists, physical therapists, and dietitians. Physicians trained in other specialties, such as anesthesiology, cardiology, radiology, surgery, neurology, pediatrics, and orthopedics, may be consulted and called to the ICU to treat patients who require their expertise. Radiologic technologists perform mobile x ray examinations (bedside radiography). Either nurses or clinical laboratory personnel perform point-of-care blood analysis. Equipment in the ICU is maintained and repaired by hospital biomedical engineering staff and/or the equipment manufacturer. Some studies have shown that patients in the ICU following high-risk surgery are at least three times as likely to survive when cared for by "intensivists," physicians trained in critical care medicine.

2.DIALYSIS CENTER
In medicine, dialysis is primarily used to provide an artificial replacement for lost kidney function (renal replacement therapy) due to renal failure. Dialysis may be used for very sick patients who have suddenly but temporarily, lost their kidney function (acute renal failure) or for quite stable patients who have permanently lost their kidney function (stage 5 chronic kidney disease).

For patients with stage 5, or End-Stage Kidney Disease (ESKD), the decline in kidney function occurred over a period of months to years until a level was reached at which treatment was needed for survival. Unlike Acute Renal Failure (ARF) (Acute Kidney Injury (AKI)), Chronic Kidney Failure cannot be cured or reversed and long-term treatments are needed to replace the lost functions of the kidney. The treatment for ESKD that most naturally replaces lost kidney function is a kidney transplant. However, some patients are not good candidates for a transplant due to medical or other reasons, some cannot receive a transplant because of the short supply of donor kidneys, and others simply decide that a transplant is not the best option for them. As a result, most patients with ESKD must rely on dialysis to replace the water and waste removal functions of the healthy kidneys. The kidneys have important roles in maintaining health. When healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate). Those acidic metabolism end products that the body cannot get rid of via respiration are also excreted through the kidneys. The kidneys also function as a part of the endocrine system producing erythropoietin and 1,25-dihydroxycholecalciferol (calcitriol).

Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in bone formation. Dialysis is an imperfect treatment to replace kidney function because it does not correct the endocrine functions of the kidney. Dialysis treatments replace some of these functions through diffusion (waste removal) and ultrafiltration (fluid removal). DIALYSIS TYPES: Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across a semi-permeable membrane. Diffusion describes a property of substances in water. Substances in water tend to move from an area where they are in a high concentration to an area of low concentration. Blood flows by one side of a semi-permeable membrane, and a dialysate, or special dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer of material that contains various sized holes, or pores. Smaller solutes and fluid pass through the membrane, but the membrane blocks the passage of larger substances (for example, red blood cells, large proteins). The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several litres of excess fluid during a typical 3 to 5 hour treatment. In the US, hemodialysis treatments are typically given in a dialysis center three times per week (due in the US to Medicare reimbursement rules); however, as of 2007 over 2,500 people in the US are dialyzing at home more frequently for various treatment lengths. Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. These frequent long treatments are often done at home, while sleeping but home dialysis is a flexible modality and schedules can be changed day to day, week to week. In general, studies have shown that both increased treatment length and frequency are clinically beneficial.

PERITONEAL DIALYSIS:
In peritoneal dialysis, a sterile solution containing minerals and glucose is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal membrane acts as a semipermeable membrane.The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that lines and surrounds the peritoneal, or abdominal, cavity and the internal abdominal organs (stomach, spleen, liver, and intestines). The dialysate is left there for a period of time to absorb waste products, and then it is drained out through the tube and discarded.

This cycle or "exchange" is normally repeated 4-5 times during the day, (sometimes more often overnight with an automated system). Ultrafiltration occurs via osmosis; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than was instilled. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis. Peritoneal dialysis is carried out at home by the patient. Although support is helpful, it is not essential. It does free patients from the routine of having to go to a dialysis clinic on a fixed schedule multiple times per week, and it can be done while travelling with a minimum of specialized equipment.

HEMOFILTRATION:
Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used.

A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, importantly ones with large molecular weights, which are cleared less well by hemodialysis. Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal circuit during the treatment. Hemodiafiltration is a term used to describe several methods of combining hemodialysis and hemofiltration in one process.
INDICATIONS FOR DIALYSIS:

The decision to initiate dialysis or hemofiltration in patients with renal failure depends on several factors. These can be divided into acute or chronic indications. Indications for dialysis in the patient with acute kidney injury are: Metabolic acidosis in situations where correction with sodium bicarbonate is impractical or may result in fluid overload. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI.

Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, or aspirin. Fluid overload not expected to respond to treatment with diuretics. Complications of uremia, such as pericarditis, encephalopathy, or gastrointestinal bleeding. Chronic indications for dialysis: Symptomatic renal failure Low glomerular filtration rate (GFR) (RRT often recommended to commence at a GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier. Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low.

3.COMPUTED TOMOGRAPHY(CT)
A computed tomography (CT) scan uses X-rays to make detailed pictures of structures inside of the body. During the test, you will lie on a table that is attached to the CT scanner, which is a large doughnut-shaped machine. The CT scanner sends X-rays through the body area being studied. Each rotation of the scanner provides a picture of a thin slice of the organ or area. All of the pictures are saved as a group on a computer. They also can be printed. In some cases, a dye called contrast material may be used. It may be put in a vein (IV) in your arm, or it may be placed into other parts of your body (such as the rectum or a joint) to see those areas better. For some types of CT scans you drink the dye. The dye makes structures and organs easier to see on the CT pictures. A CT scan can be used to study all parts of your body, such as the chest, belly, pelvis, or an arm or leg. It can take pictures of body organs, such as the liver, pancreas, intestines, kidneys, bladder, adrenal glands, lungs, and heart. It also can study blood vessels, bones, and the spinal cord. Fluoroscopy CT is a special test that is not widely available. It uses a steady beam of X-rays to look at movement within the body. It allows the doctor to see your organs move or to guide a biopsy needle or other instrument into the right place inside your body.

SPIRAL CAT SCAN:

A conventional computerized axial tomography scan (CAT scan or CT scan) is an x-ray procedure which combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. A CAT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments.

A spiral CAT scan is a new specialized CAT scan technique that involves continuous movement of the patient through the scanner with the ability to scan faster and with higher definition of internal structures. Spiral CAT scanning can permit greater visualization of blood vessels and internal tissues, such as those within the chest cavity. This form of scanner may be particularly helpful in the rapid evaluation of severe trauma injuries, such as those sustained in automobile accidents. A spiral CAT scan is also referred to as helical CAT scan.

WHY IT IS DONE:
CT scans are used to study areas of the body and the arms or legs.

Chest (thorax) A CT scan of the chest can look for problems with the lungs, heart, esophagus, the major blood vessel (aorta), or the tissues in the center of the chest. Some common chest problems a CT scan may find include infection, lung cancer, a pulmonary embolism, and an aneurysm. AbdomenA CT scan of the abdomen can find cysts, abscesses, infection, tumors, an aneurysm, enlarged lymph nodes, foreign objects, bleeding in the belly, diverticulitis, inflammatory bowel disease, and appendicitis.

Urinary tractA CT scan of the kidneys, ureters, and bladder is called a CT KUB or CT urogram. This type of scan can find kidney stones, bladder stones, or blockage of the urinary tract. See a picture of a CT of diseased kidneys. A special type of CT scan, called a CT intravenous pyelogram (IVP), uses injected dye (contrast material) to look for kidney stones, blockage, growths, infection, or other diseases of the urinary tract. Liver A CT scan can find liver tumors, bleeding from the liver, and liver diseases. A CT scan of the liver can help determine the cause of jaundice. PancreasA CT scan can find a tumor in the pancreas or inflammation of the pancreas (pancreatitis). Gallbladder and bile ductsA CT scan can be used to check for blockage of the bile ducts. Gallstones occasionally show up on a CT scan. But other tests, such as ultrasound, usually are used to find problems with the gallbladder and bile ducts. Adrenal glandsA CT scan can find tumors or enlarged adrenal glands. SpleenA CT scan can be used to check for an injury to the spleen or the size of the spleen. PelvisA CT scan can look for problems of organs in the pelvis. For a woman, these include the uterus, ovaries, and fallopian tubes. For a man, the pelvic organs include the prostate gland and the seminal vesicles. Arm or legA CT scan can look for problems of the arms or legs, including the shoulder, elbow, wrist, hand, hip, knee, ankle, or foot.

OTHER USES FOR A CT SCAN:

A CT scan may be used to make sure a procedure is done correctly. For example, the doctor may use CT to guide a needle during a tissue biopsy or to guide the proper placement of a needle to drain an abscess. For people with cancer, a CT scan can help determine how much the cancer has spread. This is called staging the cancer.

HOW TO PREPARE:
Before the CT scan, tell your doctor if you: Are or might be pregnant. Are allergic to any medicines, including iodine dyes. Have a heart condition, such as heart failure. Have diabetes or take metformin (Glucophage) for your diabetes. You may have to adjust your medicine for a day before and after the test. Have had kidney problems. Have asthma. Have a medical device, such as a pacemaker or an insulin pump. Have had multiple myeloma. Have had an X-ray test using barium contrast material (such as a barium enema) or have taken a medicine that contains bismuth (such as PeptoBismol) in the past 4 days. Barium and bismuth show up on X-ray films and make it hard to see the picture clearly. Become very nervous in small spaces. You need to lie still inside the CT scanner, so you may need a medicine (sedative) to help you relax. Arrange for someone to take you home in case you get a medicine to help you relax (sedative) for the test.

If you have a CT scan of your belly, you may be asked to not eat any solid foods starting the night before your scan. For a CT scan of the belly, you may drink contrast material. For some CT scans, you may need a laxative or an enema before the test.

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form.

HOW IT IS DONE:
A CT scan is usually done by a radiology technologist. The pictures are usually read by a radiologist, who writes the report. Other doctors also may review a CT scan. You may need to take off any jewelry. You will need to take off all or most of your clothes, depending on which area is studied. You may be able to wear your underwear for some scans. You will be given a gown to use during the test. During the test, you will lie on a table that is attached to the CT scanner. The table slides into the round opening of the scanner, and the scanner moves around your body. The table will move while the scanner takes pictures. You may hear a click or buzz as the table and scanner move. It is very important to lie still during the test. During the test, you may be alone in the scanning room. But the technologist will watch you through a window. You will be able to talk to the technologist through a two-way intercom. The test will take about 30 to 60 minutes. Most of this time is spent getting ready for the scan. The actual scan only takes a few seconds.

HOW IT FEELS:
The test will not cause pain. The table you lie on may feel hard, and the room may be cool. It may be hard to lie still during the test. Some people feel nervous inside the CT scanner.

If a medicine to help you relax (sedative) or dye (contrast material) is used, an IV is usually put in your hand or arm. You may feel a quick sting or pinch when the IV is started. The dye may make you feel warm and flushed and give you a metallic taste in your mouth. Some people feel sick to their stomachs or get a headache. Tell the technologist or your doctor how you are feeling.

RISKS:
The chance of a CT scan causing a problem is small.

There is a chance of an allergic reaction to the dye (contrast material). If you have diabetes or take metformin (Glucophage), the dye may cause problems. Your doctor will tell you when to stop taking metformin and when to start taking it again after the test so you will not have problems. There is a small chance of developing cancer from having some types of CT scans.1 The chance is higher in children, young adults, and people who have many radiation tests. If you are concerned about this risk, talk to your doctor about the amount of radiation this test may give you or your child and confirm that the test is needed. There is a slight risk that the CT scan can interfere with implanted or external medical devices. Examples of medical devices include pacemakers, insulin pumps, defibrillators, and neurostimulators.

RESULTS:

A computed tomography (CT) scan uses X-rays to make detailed pictures of structures the inside of the body. The radiologist may discuss the CT scan with you right after the test. Complete results usually are ready for your doctor in 1 to 2 days.

CT SCAN Normal: The organs and blood vessels are normal in size, shape, and location. No blood vessels are blocked. No foreign objects (such as metal or glass fragments), growths (such as cancer), inflammation, or infection are present. No bleeding or collections of fluid are present. Abnormal: An organ is too large or too small, damaged, or infected. Cysts or abscesses are present. Foreign objects (such as metal or glass fragments) are present. Kidney stones or gallstones are present. Growths (such as tumors) are seen in the colon, lungs, ovaries, liver, bladder, kidneys, adrenal gland, or pancreas. A CT scan of the chest shows a pulmonary embolism, fluid in the lungs, or infection. An aneurysm is present. Blockage is found in the intestines or in the bile ducts. A CT of the belly shows inflammatory bowel disease or diverticulitis. Lymph nodes are enlarged. One or more blood vessels are blocked. A growth, fracture, infection, or other problem is found in an arm or leg.

WHAT AFFECTS THE TEST:

The following may stop you from having the test or may change the test results: Pregnancy. CT scans are not usually done during pregnancy. Barium and bismuth used for another test. These substances show up on a CT scan. If a CT scan of the belly is needed, it should be done before any tests that use barium, such as a barium enema. Metal objects in the body. These items, such as surgical clips or metal in joint replacements, may prevent a clear view of the body area. You are not able to lie still during the test.

WHAT TO THINK ABOUT:

Sometimes your CT test results may be different than those from other types of X-ray tests, magnetic resonance imaging (MRI), or ultrasound scans because the CT scan provides a different view. An ultrasound test, which doesn't use dangerous radiation, may give results similar to a CT scan. If you are concerned about radiation exposure, ask your doctor if you can have an ultrasound instead of a CT scan. Children who need a CT scan may need special instructions for the test. The child will likely need to hold his or her breath during the scan. If the child is too young to hold still or is afraid, the doctor may give the child a medicine (sedative) to help him or her relax. If your child is scheduled for a CT scan, talk with your child's doctor about the need for the scan and the risk of radiation exposure to your child. Special CT scanners called spiral (helical) CT scanners and multi-slice (or multidetector) CT scanners are sometimes used for this test. Many modern scanners are multi-slice scanners. These scanners can be used for many conditions, such as finding kidney stones, a pulmonary embolism, an enlarged prostate gland, or atherosclerosis. These special CT scanners can: Take better pictures of blood vessels and organs so other imaging tests may not be needed. Complete scans and provide pictures in less time.

CT results are often compared to positron emission tomography (PET) results to help find cancer. Some new scanners do both scans at the same time. An electron beam CT scan is another type of CT scan that can find atherosclerosis and coronary artery disease. An electron beam CT scan is much faster than a standard CT scan and can take a good picture of a coronary artery while the heart is beating. Electron beam CT scans are not widely available. Another type of CT scanner, the multi-slice CT scan, is nearly as fast as electron beam CT scanners and is more widely available. A CT angiogram can show two- and three-dimensional pictures of blood vessels. For more information, see the topic Angiogram of the Head and Neck. Coronary calcium scans can help find out risk of heart disease. This test is not done very often, because a physical exam and other tests often give enough information about your heart. This test is not advised for routine screening. MRI may give different information than a CT scan about certain conditions. For more information, see the topic Magnetic Resonance Imaging (MRI). Experts disagree about the use of a CT method called full-body scanning to screen for coronary artery disease and cancers. Full-body scanning is expensive, can lead to unnecessary tests or surgery, and may increase the chance of cancer from the radiation exposure. Most doctors do not recommend these studies unless a person has a specific risk for a certain disease.

4.MAGNETIC RESONANCE IMAGING(MRI)

WHAT IS AN MRI SCAN?
An MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. For some procedures, contrast agents, such as gadolinium, are used to increase the accuracy of the images.

BASIC COMPONENTS OF MRI MACHINE:

The three basic components of the MRI machine are: The primary magnet The largest part of the MRI is the primary magnet. Developing a magnetic field of adequate strength to create MRI images was an early hurdle to overcome in the development of this technology. The gradient magnets The gradient magnets are the 'fine-tuning' part of the MRI machine. They allow the MRI to focus on a specific part of the body. The gradient magnets are also responsible for the 'clanging' noise in a MRI. The coil Next to the part of your body being imaged is the coil. There are coils made for shoulders, knees, and other body parts. The coil will emit a radiofrequency that makes a MRI possible.

THE PRIMARY MAGNET:

A permanent magnet (like the kind you use on your refrigerator door) powerful enough to use in a MRI would be too costly to produce and too cumbersome to store. The other way to make a magnet is to coil electrical wire and run a current through the wire. This creates a magnetic field within the center of the coil. In order to create a strong enough magnetic field to perform MRI, the coils of wire must have no resistance; therefore they are bathed in liquid helium at a temperature 450 degrees Fahrenheit below zero! This allows the coils to develop magnetic fields of 1.5 to 3 Tesla (the strength of most medical MRIs), more than 20,000 times stronger than the earth's magnetic field.

THE GRADIENT MAGNETS:

There are three smaller magnets within a MRI machine called gradient magnets. These magnets are much smaller that the primary magnet (about 1/1000 as strong), but they allow the magnetic field to be altered very precisely. It is these gradient magnets that allow image "slices" of the body to be created. By altering the gradient magnets, the magnetic field can be specifically focused on a selected part of the body.

THE COIL:
MRI uses properties of hydrogen atoms to distinguish between different tissues within the human body. The human body is composed primarily of hydrogen atoms (63%), other common elements are oxygen (26%), carbon (9%), nitrogen (1%), and relatively small amounts of phosphorus, calcium, and sodium. MRI uses a property of atoms called "spin" to distinguish differences between tissues such as muscle, fat, and tendon. With a patient in a MRI machine, and the magnet turned on, the nuclei of the hydrogen atoms tend to spin in one of two directions. These hydrogen atom nuclei can transition their spin orientation, or precess, to the opposite orientation. In order to spin the other direction, the coil emits a radiofrequency (RF) that causes this transition (the frequency of energy required to make this transition is specific, and called the Larmour Frequency). The signal that is used in creating MRI images is derived from the energy released by molecules transitioning, or precessing, from their high-energy to their lowenergy state. This exchange of energy between spin states is called resonance, and thus the name magnetic resonance imaging.

WORKING:
The coil also functions to detect the energy given off by magnetic induction from the precessing of the atoms. A computer interprets the data, and creates images that display the different resonance characteristics of different tissue types. We see this as an image of shades of grey--some body tissues show up darker or lighter, all depending on the above processes.

DIFFERENT TYPES OF MRI SCANS:

There are various types of MRI scans that may be ordered by your doctor.

A Head MRI can look at the brain for tumors, an aneurysm, bleeding in the brain, nerve injury, and other problems, such as damage caused by a stroke. A head MRI can also find problems of the eyes and optic nerves, and the ears and auditory nerves.

A Chest MRI can look at the heart, the heart valves, and coronary blood vessels. It can show if the heart or lungs are damaged. An MRI of the chest may also be used to look for breast or lung cancer. These can also be ordered after a mammogram exam has been given to see areas of the breast tissue in more detail. MRA or magnetic resonance angiography is a type of magnetic resonance image (MRI) scan. MRI scans are used to look at blood vessels, and the flow of blood through them is called magnetic resonance angiography (MRA). MRA scans can find problems of the arteries and veins, such as an aneurysm, a blocked blood vessel, or the torn lining of a blood vessel (dissection). Sometimes contrast material is used to see the blood vessels more clearly. Like an MRI, magnetic resonance angiograms (MRA) use a magnetic field and pulses of radio wave energy to make pictures of blood vessels inside the body. Abdomen and pelvis MRI scans can find problems in the organs and structures in the belly, such as the liver, gallbladder, pancreas, kidneys, and bladder. They can be used to find tumors, bleeding, infection, and blockage. In women, MRI scans can look at the uterus and ovaries. In men, they can look at the prostate.

Bone and joint MRIs can check for problems such as arthritis, problems with the temporomandibular joint, bone marrow problems, bone tumors, cartilage problems, torn ligaments or tendons, or infection. These MRI scans may also be used to tell if a bone is broken when X-ray results are not clear. MRI scans are done more commonly than other tests to check for some bone and joint problems. A Spine MRI can check the discs and nerves of the spine for conditions such as spinal stenosis, disc bulges, and spinal tumors.

WHEN ARE MRI SCANS USED?

An MRI scan can be used as an extremely accurate method of disease detection throughout the body. In the head, trauma to the brain can be seen as bleeding or swelling. Other abnormalities often found include brain aneurysms,stroke, tumors of the brain, as well as tumors or inflammation of the spine. Neurosurgeons use an MRI scan not only in defining brain anatomy but in evaluating the integrity of the spinal cord after trauma. It is also used when considering problems associated with the vertebrae or intervertebral discs of the spine. An MRI scan can evaluate the structure of the heart and aorta, where it can detectaneurysms or tears. It provides valuable information on glands and organs within the abdomen, and accurate information about the structure of the joints, soft tissues, and bones of the body. Often, surgery can be deferred or more accurately directed after knowing the results of an MRI scan.

WHY IT IS DONE:
Magnetic resonance imaging (MRI) is done for many reasons. It is used to find problems such as tumors, bleeding, injury, blood vessel diseases, or infection. MRI also may be done to provide more information about a problem seen on an X-ray, ultrasound scan, or CT scan. Contrast material may be used during MRI to show abnormal tissue more clearly. An MRI scan can be done for the: HeadMRI can look at the brain for tumors, an aneurysm, bleeding in the brain, nerve injury, and other problems, such as damage caused by a stroke. MRI can also find problems of the eyes and optic nerves, and the ears and auditory nerves. ChestMRI of the chest can look at the heart, the valves, and coronary blood vessels. It can show if the heart or lungs are damaged. MRI of the chest may also be used to look for breast or lung cancer. Blood vesselsUsing MRI to look at blood vessels and the flow of blood through them is called magnetic resonance angiography (MRA). It can find problems of the arteries and veins, such as an aneurysm, a blocked blood vessel, or the torn lining of a blood vessel (dissection). Sometimes contrast material is used to see the blood vessels more clearly. Abdomen and pelvisMRI can find problems in the organs and structures in the belly, such as the liver, gallbladder, pancreas, kidneys, and bladder. It is used to find tumors, bleeding, infection, and blockage. In women, it can look at the uterus and ovaries. In men, it looks at the prostate. Bones and jointsMRI can check for problems of the bones and joints, such as arthritis, problems with the temporomandibular joint, bone marrow problems, bone tumors, cartilage problems, torn ligaments or tendons, or infection. MRI may also be used to tell if a bone is broken when X-ray results are not clear. MRI is done more commonly than other tests to check for some bone and joint problems. SpineMRI can check the discs and nerves of the spine for conditions such as spinal stenosis, disc bulges, and spinal tumors.

HOW DOES A PATIENT PREPARE FOR AN MRI SCAN AND HOW IS IT PERFORMED?
All metallic objects on the body are removed prior to obtaining an MRI scan. Occasionally, patients will be given a sedative medication to decrease anxiety and relax the patient during the MRI scan. MRI scanning requires that the patient lie still for best accuracy. Patients lie within a closed environment inside the magnetic machine. Relaxation is important during the procedure and patients are asked to breathe normally. Interaction with the MRI technologist is maintained throughout the test. There are loud, repetitive clicking noises which occur during the test as the scanning proceeds. Occasionally, patients require injections of liquid intravenously to enhance the images which are obtained. The MRI scanning time depends on the exact area of the body studied, but ranges from half an hour to an hour and a half.

HOW IT FEELS:
You will not have pain from the magnetic field or radio waves used for the MRI test. The table you lie on may feel hard and the room may be cool. You may be tired or sore from lying in one position for a long time. If a contrast material is used, you may feel some coolness and flushing as it is put into your IV. In rare cases, you may feel:

A tingling feeling in the mouth if you have metal dental fillings. Warmth in the area being examined. This is normal. Tell the technologist if you have nausea, vomiting, headache, dizziness, pain, burning, or breathing problems.

RISKS:
An MRI scan is a painless radiology technique that has the advantage of avoiding xray radiation exposure. There are no known side effects of an MRI scan. The benefits of an MRI scan relate to its precise accuracy in detecting structural abnormalities of the body.

Patients who have any metallic materials within the body must notify their physician prior to the examination or inform the MRI staff. Metallic chips, materials, surgical clips, or foreign material (artificial joints, metallic bone plates, or prosthetic devices, etc.) can significantly distort the images obtained by the MRI scanner. Patients who have heart pacemakers, metal implants, or metal chips or clips in or around the eyeballs cannot be scanned with an MRI because of the risk that the magnet may move the metal in these areas. Similarly, patients with artificial heart valves, metallic ear implants, bullet fragments, and chemotherapy or insulin pumps should not have MRI scanning. During the MRI scan, patient lies in a closed area inside the magnetic tube. Some patients can experience a claustrophobic sensation during the procedure. Therefore, patients with any history of claustrophobia should relate this to the practitioner who is requesting the test, as well as the radiology staff. A mild sedative can be given prior to the MRI scan to help alleviate this feeling. It is customary that the MRI staff will be nearby during MRI scan. Furthermore, there is usually a means of communication with the staff (such as a buzzer held by the patient) which can be used for contact if the patient cannot tolerate the scan. There are no known harmful effects from the strong magnetic field used for MRI. But the magnet is very powerful. The magnet may affect pacemakers, artificial limbs, and other medical devices that contain iron. The magnet will stop a watch that is close to the magnet. Any loose metal object has the risk of causing damage or injury if it gets pulled toward the strong magnet. Metal parts in the eyes can damage the retina. If you may have metal fragments in the eye, an X-ray of the eyes may be done before the MRI. If metal is found, the MRI will not be done.Iron pigments in tattoos or tattooed eyeliner can cause skin or eye irritation.An MRI can cause a burn with some medication patches. Be sure to tell your health professional if you are wearing a patch. There is a slight risk of an allergic reaction if contrast material is used during the MRI. But most reactions are mild and can be treated using medicine. There also is a slight risk of an infection at the IV site.

RESULTS:
A magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. The radiologist may discuss initial results of the MRI with you right after the test. Complete results are usually ready for your doctor in 1 to 2 days.An MRI can sometimes find a problem in a tissue or organ even when the size and shape of the tissue or organ looks normal. MAGNETIC RESONANCE IMAGING (MRI) Normal: The organs, blood vessels, bones, and joints are normal in size, shape, appearance, and location. No abnormal growths, such as tumors, are present. No bleeding, abnormal fluid, blockage in the flow of blood, or bulges in the blood vessels (aneurysms) are present. No signs of inflammation or infection are present. Abnormal: An organ is too large, too small, damaged, or absent. Abnormal growths (such as tumors) are present. Abnormal fluid from a cause such as bleeding or an infection is present. Fluid is found around the lungs or heart. Fluid is found around the liver, bowel, or other organ in the abdomen. A blood vessel is narrowed or blocked. An aneurysm is present. Blockage in the gallbladder bile ducts or in the tubes (ureters) that lead out of the kidneys is present. Damage to joints, ligaments, or cartilage is seen. Bones are broken or show infection or disease. Problems of the nervous system are present, such as multiple sclerosis

(MS), dementia, Alzheimer's disease, or herniated disc.

HOW DOES A PATIENT OBTAIN THE RESULTS OF THE MRI SCAN?

After the MRI scanning is completed, the computer generates visual images of the area of the body that was scanned. These images can be transferred to film (hard copy). A radiologist is a physician who is specially trained to interpret images of the body. The interpretation is transmitted in the form of a report to the practitioner who requested the MRI scan. The practitioner can then discuss the results with the patient and/or family.

FUTURE:
Scientists are developing newer MRI scanners that are smaller, portable devices. These new scanners apparently can be most useful in detecting infections and tumors of the soft tissues of the hands, feet, elbows, and knees. The application of these scanners to medical practice is now being tested.

5.X-RAY
DEFINITION:
X rays are electromagnetic radiation that differentially penetrates structures within the body and creates images of these structures on photographic film or a fluorescent screen. These images are called diagnostic x rays.

PURPOSE:
Diagnostic x rays are useful in detecting abnormalities within the body. They are a painless, non-invasive way to help diagnose problems such as broken bones, tumors, dental decay, and the presence of foreign bodies.

DESCRIPTION:
X rays are a form of radiation similar to light rays, except that they are more energetic than light rays and are invisible to the human eye. They are created when an electric current is passed through a vacuum tube. X rays were accidentally discovered in 1895 by German physicist Wilhem Roentgen (1845-1923), who was later awarded the first Nobel Prize in physics for his discovery. Roentgen was also a photographer and almost immediately realized that the shadows created when x rays passed through the body could be permanently recorded on photographic plates. His first x-ray picture was of his wife's hand. Within a few years, x rays became a valued diagnostic tool of physicians world-wide.

HOW X RAYS WORK :

X rays pass easily through air and soft tissue of the body. When they encounter more dense material, such as a tumor, bone, or a metal fragment, they are stopped. Diagnostic x rays are performed by positioning the part of the body to be examined between a focused beam of x rays and a plate containing film. This process is painless. The greater the density of the material that the x rays pass through, the more rays are absorbed. Thus bone absorbs more x rays than muscle or fat, and tumors may absorb more x rays than surrounding tissue. The x rays that pass through the body strike the photographic plate and interact with silver molecules on the surface of the film.

nce the film plates have been processed, dense material such as bone shows up as white, while softer tissue shows up as shades of gray, and airspaces look black. A radiologist, who is a physician trained to interpret diagnostic x rays, examines the pictures and reports to the doctor who ordered the tests. Plain film x rays normally take only a few minutes to perform and can be done in a hospital, radiological center, clinic, doctor's or dentist's office, or at bedside with a portable x-ray machine.

SPECIAL TYPES OF X-RAY PROCEDURES:

Mammograms are fixed plate x rays that are designed to locate tumors within the breasts. Dental x rays are designed to locate decay within the tooth. Sometimes a liquid called contrast material (for example, barium) is used to help outline internal organs such as the intestines. The contrast material absorbs x rays, helping to make soft tissue more easily visible on the x-ray films. Contrast material is commonly used in making x rays of the digestive system. The contrast liquid can be swallowed or injected, depending on the part of the body being x rayed. This may cause some minor discomfort. Fluoroscopy is a special x-ray technique that produces real-time images on a television monitor. With fluoroscopy, contrast material is injected into a blood vessel. The physician can then watch the real-time movement of the contrast material to determine if there are blockages in circulation. Fluoroscopy is also used to help guide catheters into place in the heart during cardiac catheterization or to guide an endoscope during endoscopic surgery. Computed tomography or CT scan works on the same principles as fixed plate x rays, only with a CT scan, an x ray tube rotates around the individual, taking hundreds of images that are then compiled by a computer to produce a twodimensional cross section of the body. Although many images are taken to produce a CT scan, the total dose of radiation the individual is exposed to is low. Other common imaging techniques such as magnetic resonance imaging (MRI) and ultrasound do not use x rays.

HOW X RAYS ARE PERFORMED:

Fixed plate x rays are extremely common diagnostic tests. A trained x-ray technologist takes the x ray. The individual is first asked to remove clothing and jewelry and to wear a hospital gown. The x ray technologist positions the patient appropriately, so that the part of the body to be x rayed will be between the x-ray beam and the film plate. Usually the individual either lies on an adjustable table or stands.

Parts of the body that are especially sensitive to damage by x rays (for example, the reproductive organs, the thyroid) are shielded with a lead apron. Lead is very dense and effectively protects the body by stopping all x rays. It is essential to remain motionless during the x ray, since movement causes the resulting picture to be blurry. Sometimes patients are asked to hold their breath briefly during the procedure. Children who are not old enough follow directions or who cannot stay still may need to be restrained or given medication to sedate them in order to keep them still enough to obtain useful results. Sometimes parents can stay with children during an x ray, unless the mother is pregnant, in which case she must protect the fetus from x-ray exposure. If a contrast material is to be used, the individual will be given special instructions to prepare for the procedure and may be asked to remain afterwards until recovery is complete. (See Preparation and Aftercare below.)

PRECAUTIONS :
Although unnecessary exposure to radiation should be avoided, the low levels of radiation one is exposed to during an x ray does not cause harm with a few exceptions. Pregnant women should not have x rays unless in emergencies the benefits highly outweigh the risks. Exposure of the fetus to x rays, especially during early pregnancy can increase the risk of the child later developing leukemia. Body parts not being x rayed should be shielded with a lead apron, especially the testes, ovaries, and thyroid.

PREPARATION :
No special preparation is needed for fixed plate x rays unless contrast material is used. When x rays are scheduled that involve the use of contrast material, the physician will give specific instructions for preparation. For example, in a lower GI series, the individual may have to fast and use special laxatives to cleanse the bowel before swallowing the contrast material.

KEY TERMS:
Contrast agent Also called a contrast medium, this is usually a barium or iodine dye that is injected into the area under investigation. The dye makes the interior body parts more visible on an x-ray film. Electromagnetic radiation Packets of energy that develop when an electric current passes through a vacuum tube. Endoscope A medical instrument that can be passed into an area of the body (the bladder or intestine, for example) to allow visual examination of that area. The endoscope usually has a fiberoptic camera that allows a greatly magnified image to be shown on a television screen viewed by the operator. Many endoscopes also allow the operator to retrieve a small sample (biopsy) of the area being examined, to more closely view the tissue under a microscope.

RISKS:
Low dose exposure to x rays creates minimal cell damage and minimal risk when x rays are performed in an accredited facility. There is an increased risk that a developing fetus will develop leukemia during childhood if exposed to x-ray radiation; pregnant or potentially pregnant women should avoid x rays. There is also a slight risk of an allergic reaction to the contrast material or dye used in certain x rays.

6.ECHOCARDIOGRAM AND TMT

ECHOCARDIOGRAM:
Echocardiogram, often referred to cardiac echo or simply an echo is a sonogram of the heart. (It is not abbreviated as ECG, which in medicine usually refers to an electrocardiogram.) Echocardiography uses standard two-Dimensional, three-dimensional, and Doppler ultrasound to create images of the heart. Echocardiography has become routinely used in the diagnosis, management, and follow-up of patients with any suspected or known heart diseases. It is one of the most widely used diagnostic tests in cardiology. It can provide a wealth of helpful information, including the size and shape of the heart (internal chamber size quantification), pumping capacity, and the location and extent of any tissue damage. An Echocardiogram can also give physicians other estimates of heart function such as a calculation of the cardiac output, ejection fraction, and diastolic function . Echocardiography can help detect cardiomyopathies, such as hypertrophic cardiomyopathy, dilated cardiomyopathy, and many others. The use of Stress Echocardiography may also help determine whether any chest pain or associated symptoms are related to heart disease. The biggest advantage to echocardiography is that it is noninvasive (doesn't involve breaking the skin or entering body cavities) and has no known risks or side effects. Not only can an echocardiogram create ultrasound images of heart structures, but it can also produce accurate assessment of the blood flowing through the heart, using pulsed or continuous wave Doppler ultrasound. This allows assessment of both normal and abnormal blood flow through the heart. Color Doppler as well as spectral Doppler is used to visualize any abnormal communications between the left and right side of the heart, any leaking of blood through the valves (valvular regurgitation), and to estimate how well the valves open (or do not open in the case of valvular stenosis). Echocardiography was also the first ultrasound subspecialty to use intravenous contrast. (See Contrast Echocardiography) Echocardiography is performed by cardiac sonographers, cardiac physiologists (UK) or doctors trained in echocardiography.

WHY HAS YOUR DOCTOR ORDERED A STRESS ECHOCARDIOGRAM? Identify cause of chest pain, which can occur with blockages in blood flow to heart. Monitor heart function in people with known heart disease. Determine response to treatments after angioplasty or bypass surgery, or response to medications. HOW DO I PREPARE FOR A STRESS ECHOCARDIOGRAM? Do not eat 2 hours prior to your test. Avoid caffeine 12 hours prior to your test. Do not smoke or use any form of nicotine 12 hours prior to your test. Take you medications on the day of the test unless instructed otherwise. Do not apply lotions or powders to the chest. Wear loose, comfortable clothing and walking shoes.

WHAT HAPPENS DURING THE STRESS ECHOCARDIOGRAM? You will be given an explanation of the test and asked to sign a consent form. Electrodes are placed on your chest and connected by wires to the ECG machine. While you lie on a exam table, an echo technician moves the transducer over your chest to obtain images of your heart. A nurse or exercise physiologist supervises the stress portion while you exercise. Your blood pressure is checked frequently, and your ECG is continually monitored. Report any symptoms, such as chest pain, shortness of breath or dizziness. Exercise as long as you can since that increases the accuracy of the test. When you reach to point that you do not feel that you can exercise any longer, the treadmill is stopped abruptly and you return to the exam table. Post-exercise images of your heart are obtained. Your blood pressure and ECG will be monitored for several minutes after the test.

TRANSTHORACIC ECHOCARDIOGRAM (TTE) A standard echocardiogram is also known as a transthoracic echocardiogram (TTE), or cardiac ultrasound. In this case, the echocardiography transducer (or probe) is placed on the chest wall (or thorax) of the subject, and images are taken through the chest wall. This is a non-invasive, highly accurate and quick assessment of the overall health of the heart. A cardiologist or cardiac physiologist can quickly assess a patient's heart valves and degree of heart muscle contraction (an indicator of the ejection fraction). The images are displayed on a monitor, and are recorded either by videotape (analog) or by digital techniques. An echocardiogram can be used to evaluate all four chambers of the heart. It can determine strength of the heart, the condition of the heart valves, the lining of the heart (the endocardium), and the aorta. It can be used to detect a heart attack, enlargement or hypertrophy of the heart, infiltration of the heart with an abnormal substance. Weakness of the heart, cardiac tumors, and a variety of other findings can be diagnosed with an echocardiogram. With advanced measurements of the movement of the tissue with time (tissue doppler), it can measure diastolic function, fluid status, and dys-synchrony. The TTE is highly accurate for identifying vegetations (masses consisting of a mixture of bacteria and blood clots), but the accuracy can be reduced in up to 20% of adults because of obesity,chronic obstructive pulmonary disease, chest-wall deformities, or otherwise technically difficult patients. TTE in adults is also of limited use for the structures at the back of the heart, such as the left atrial appendage. Transesophageal echocardiography may be more accurate than TTE because it excludes the variables previously mentioned and allows closer visualization of common sites for vegetations and other abnormalities. Transesophageal echocardiography also affords better visualization of prosthetic heart valves. "Bubble contrast TTE" involves the injection of agitated saline into a vein, followed by an echocardiographic study. The bubbles are initially detected in the right atrium and right ventricle. If bubbles appear in the left heart, this may indicate a shunt, such as a patent foramen ovale, atrial septal defect, ventricular septal defect or arteriovenous malformations in the lungs.

How does TEE differ from a standard ECHO? A standard echocardiogram or Echo is obtained by applying a transducer to the front of the chest. The ultrasound beam travels through the chest wall (skin, muscle, bone, tissue) and lungs to reach the heart. Because it travels through the front of the chest or thorax (pronounced thow-racks) a standard echocardiogram is also known as a TRANSTHORACIC (pronounced trans-thow-rassic) echo, as shown below (left):

At times, closely positioned ribs, obesity and emphysema may create technical difficulties by limiting the transmission of the ultrasound beams to and from the heart. In such cases, your physician may select to get a transesophageal (pronounced trans-esoff-a-gee-ul) echo, where the echo transducer is placed in the esophagus (pronounced esoff-a-gus) or food pipe that connects the mouth to the stomach. Since the esophagus sits behind the heart, the echo beam does not have to travel through the front of the chest, avoiding many of the obstacles described above. In other words, it offers a much clearer image of the heart, particularly, the back structures, such as the left atrium, which may not be seen as well by a standard echo taken from the front of the heart. This is shown in the picture above (right). How is a a TEE performed? The patient is made to lie on the left side. A sedative is given through an intravenous (IV) line to help in relaxation and the throat is sprayed with an anesthetic to "numb" it. The TEE echo transducer is much smaller than the standard Echo equipment and is positioned at the end of a flexible tube (similar to the tube used to examine the stomach during endoscopy). The tube transfers the images from the transducer to the Echo monitor. The patient begins to swallow the tube and the procedure begins. The use of anesthesia and the sedative minimizes discomfort and there is usually no pain. The tube goes down the esophagus the same way as swallowed food. Therefore, it is important that the patient swallow the tube rather than gag on it.

The transducer at the end of the tube is positioned in the esophagus, directly behind the heart. By rotating and moving the tip of the transducer, the physician can examine the heart from several different angles. The heart rate, blood pressure and breathing are monitored during the procedure. Oxygen is given as a preventive measure and suction is used, as needed. After the procedure, driving is not allowed for 12 hours (because of the use of sedatives). Eating and drinking should be avoided for at least two hours because the throat will still be numb and the food or drink could be aspirated into the lungs. Hot food and drinks should not be used for about 24 hours. The throat may be sore and throat lozenges can be used after two hours of the procedure. It is unusual to experience bleeding, persistent pain or fever. These should be reported to the physician. PREPARING FOR THE TEE:

Do not eat or drink for six hours. This will minimize the risk of vomiting and aspirating during the procedure. Medications prescribed by your doctor may be taken with sips of water, if you are not instructed to hold them. Arrange for a drive home if the procedure is performed on an outpatient basis. Be sure to notify the doctor or nurse if you have any allergies, or if you have any difficulty in swallowing or problems with your mouth, esophagus or stomach. Dentures should be removed.

How long does a TEE procedure take? You should plan to be in the cardiac lab for about two hours. The actual procedure usually lasts 10 to 30 minutes. The remainder of the time is spent in preparation and observation. How safe is TEE? TEE is a relatively common procedure and considered to be fairly safe. However, it does require entrance into your esophagus and stomach. On occasions, patients may experience breathing problems, abnormal or slow heart rhythm, reaction to the sedative and minor bleeding. In extremely rare cases TEE may cause perforation or tear of the esophagus. How soon will I get the results? The physician can usually provide the results immediately after the procedure. However, the doctor may prefer to review the tape again before giving a final report. Also, if the patient appear drowsy from the sedative, a conference may be set up for a later time.

What Information is provided by TEE? A TEE is extremely useful in detecting blood clots, masses and tumors that are located inside the heart. It can also gauge the severity of certain valve problems and help detect infection of heart valves, certain congenital heart diseases (like a hole between the upper chambers of the heart, known as an ASD or atrial septal defect) and a tear (dissection) of the aorta (major artery of the body). TEE is also very useful in evaluating patients who have had mini or major stokes as a result of blood clots. The procedure may detect the responsible clot inside the left atrium. STRESS ECHOCARDIOGRAPHY: A stress echocardiogram, also known as a stress echo or SE, utilizes ultrasound imaging of the heart to assess the wall motion in response to physical stress. First, images of the heart are taken "at rest" to acquire a baseline of the patient's wall motion at a resting heart rate. The patient then walks on a treadmill or utilizes another exercise modality to increase the heart rate to their target heart rate, or 80% of the age predicted max heart rate (age predicted max heart rate = 220 patient's age). Finally, images of the heart are taken "at stress" to assess wall motion at the peak heart rate. A stress echo assesses wall motion of the heart; it does not, however, image the coronary arteries directly. Ischemia of one or more coronary arteries could cause a wall motion abnormality which could indicate coronary artery disease (CAD). The gold standard test to directly image the coronary arteries and directly assess for stenosis or occlusion is a cardiac catheterization. A stress echo is a non-invasive test and is performed in the presence of a licensed medical professional, such as a cardiologist, and a cardiac sonographer.

HOW TO PREPARE FOR THE TEST:

There is no special preparation for the test. For a TEE, you will be asked not to eat or drink for several hours before the test.

TREADMILL TEST (TMT):

WHAT IS A TREADMILL STRESS TEST? A treadmill stress test is an exercise test that is helpful in detecting the presence of coronary artery disease. Coronary artery disease occurs when the hearts vessels become partially blocked or narrowed by the build-up of fatty materials preventing the heart from receiving the blood it needs to function properly. WHY SHOULD I HAVE A TREADMILL STRESS TEST? The test allows the doctor to compare the amount of blood flowing through the heart muscle during stress and at rest. The test results help the doctor plan your treatment and any other tests that are needed. PREPARATION: Please review with your doctor or your doctor's nurse. You may have a light meal then nothing to eat or drink for 2 hours before the test. Dont have any caffeine 24 hours before the test. This includes coffee, regular and decaffeinated, tea, chocolate, all cola drinks, soft drinks containing caffeine and over-the-counter pain relievers containing caffeine (Anacin, Excedrin). Wear comfortable clothing and shoes. You will need to stop taking Beta-Blocker medications 24 hours before the test. Check with your doctor to see if you are taking any of these medications. Bring a list of your current medication to the procedure. Please bring photo ID. PROCEDURE: After you arrive for your test several small pads (electrodes) will be placed on your chest to record your heartbeat. Your blood pressure is also monitored. Next you will meet and talk with the doctor who will interpret your test. You then begin walking at a slow rate and slight incline on the treadmill. Every three minutes the treadmill will go a little faster and the incline will increase. The time on the treadmill is different for everyone depending on his or her age and ability to exercise. After the doctor has told you to stop you will rest until your heart rate and blood pressure return to pre-exercise levels. The physician will talk with you about the results and will send the results to your physician.

7.ELECTROMYOGRAPHY (EMG)
Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles.[1] EMG is performed using an instrument called an electromyograph, to produce a record called an electromyogram. An electromyograph detects the electrical potentialgenerated by muscle cells[2] when these cells are electrically or neurologically activated. The signals can be analyzed to detect medical abnormalities, activation level, recruitment order or to analyze the biomechanics of human or animal movement. It is also used for investigate symptoms like weakness, neck pain, low back pain, numbness, tingling sensation and can localizing which nerve or nerves are involved to cause a particular problems. The EMG test can give wide information about the condition of muscles and nerve either there is damage or no.

RECORDING ELECTRODES:
The physiological response of excitable tissue to voluntary activity or electrical stimulation is recorded by recording electrodes.

Surface electrodes: (usually silver-silver chloride) are electrodes placed on the skin to collect information from superficial muscles and nerve bundles.

Needle electrodes: fine wire electrode made of platinum, silver or stainless steel, consist of one wire (monopolar) or two wires (bipolar) the wire of diameter 50 or less, this wire is inserted into the muscle through a hollow- core needle

Needle electrodes are used in diagnostic record for fine localization (motor unit), deep small muscle, and deep and small nerves. The insertions of needle electrode in tissues cause some discomfort and sometimes tissue damage due to movement of electrode.

The signals detected by voluntary contraction of muscle or by electrical stimulation of motor nerve to a particular muscle (action potentials) are very tiny with few micro-volts. The EMG machine amplified this tiny signals about thousands times to give values with milli-volts can be displayed on an oscilloscope and recorded on a chart

In denervated muscle the membrane of the diseased muscle at rest becomes hypersensitive to acetylcholine causing spontaneous potentials shown as 1ms potential of low amplitude called fibrillation potentials, positive potentials and fasciculation.

USES OF EMG:
Help in diagnosis of the diseased muscles (muscle dystrophy). Help in diagnosis of neuromuscular junction diseases. Help in diagnosis of the nerve and nerve roots diseases (which can be due to nerve damage) by measure sensory and motor conduction velocities. Used as bio-feed back for training muscle by using surface electrodes.

PROCEDURE: There are two kinds of EMG in widespread use: surface EMG and intramuscular (needle and fine-wire) EMG. To perform intramuscular EMG, a needle electrode or a needle containing two fine-wire electrodes is inserted through the skin into the muscle tissue. A trained professional (such as a neurologist, physiatrist, chiropractor, or physical therapist) observes the electrical activity while inserting the electrode. The insertional activity provides valuable information about the state of the muscle and its innervating nerve. Normal muscles at rest make certain, normal electrical signals when the needle is inserted into them. Then the electrical activity when the muscle is at rest is studied. Abnormal spontaneous activity might indicate some nerve and/or muscle damage. Then the patient is asked to contract the muscle smoothly. The shape, size, and frequency of the resulting motor unit potentials are judged. Then the electrode is retracted a few millimeters, and again the activity is analyzed until at least 1020 units have been collected. Each electrode track gives only a very local picture of the activity of the whole muscle. Because skeletal muscles differ in the inner structure, the electrode has to be placed at various locations to obtain an accurate study. Intramuscular EMG may be considered too invasive or unnecessary in some cases. Instead, a surface electrode may be used to monitor the general picture of muscle activation, as opposed to the activity of only a few fibres as observed using an intramuscular EMG. This technique is used in a number of settings; for example, in the physiotherapy clinic, muscle activation is monitored using surface EMG and patients have an auditory or visual stimulus to help them know when they are activating the muscle (biofeedback). A motor unit is defined as one motor neuron and all of the muscle fibers it innervates. When a motor unit fires, the impulse (called an action potential) is carried down the motor neuron to the muscle. The area where the nerve contacts the muscle is called the neuromuscular junction, or the motor end plate. After the action potential is transmitted across the neuromuscular junction, an action potential is elicited in all of the innervated muscle fibers of that particular motor unit. The sum of all this electrical activity is known as a motor unit action potential (MUAP). This electrophysiologic activity from multiple motor units is the signal typically evaluated during an EMG. The composition of the motor unit, the number of muscle fibres per motor unit, the metabolic type of muscle fibres and many other factors affect the shape of the motor unit potentials in the myogram. Some patients can find the procedure somewhat painful, whereas others experience only a small amount of discomfort when the needle is inserted. The muscle or muscles being tested may be slightly sore for a day or two after the procedure.

RECORDING METHODOLOGY: Electrical potential difference measured between two points bipolar electrode configuration used Bipolar Electrode Types Fine Wire------------------------ Needle Surface Most common, less invasive Silver-silver chloride electrodes Electrode Placement Overlying the muscle of interest in the direction of predominant fiber direction Subject is GROUNDED by placing an electrode in an inactive region of body NORMAL RESULTS: Muscle tissue at rest is normally electrically inactive. After the electrical activity caused by the irritation of needle insertion subsides, the electromyograph should detect no abnormal spontaneous activity (i.e., a muscle at rest should be electrically silent, with the exception of the area of the neuromuscular junction, which is, under normal circumstances, very spontaneously active). When the muscle is voluntarily contracted, action potentials begin to appear. As the strength of the muscle contraction is increased, more and more muscle fibers produce action potentials. When the muscle is fully contracted, there should appear a disorderly group of action potentials of varying rates and amplitudes (a complete recruitment and interference pattern). ABNORMAL RESULTS: EMG is used to diagnose diseases that generally may be classified into one of the following categories: neuropathies, neuromuscular junction diseases and myopathies.

Neuropathic disease has the following defining EMG characteristics: An action potential amplitude that is twice normal due to the increased number of fibres per motor unit because of reinnervation of denervated fibresAn increase in duration of the action potential. Myopathic disease has these defining EMG characteristics: A decrease in duration of the action potential A reduction in the area to amplitude ratio of the action potential A decrease in the number of motor units in the muscle (in extremely severe cases only) Because of the individuality of each patient and disease, some of these characteristics may not appear in every case.

8. ELECTROENCEPHALOGRAM(EEG)
The electroencephalogram (EEG) is a recording of the electrical activity of the brain from the scalp. The first recordings were made by Hans Berger in 1929. The electrical activity is also called brain waves.EEG is the record of electrical activity of brain( superficial layer i.e. the dendrites of pyramidal cells) by placing the electrodes on the scalp. SOURCE OF EEG ACTIVITY The brain's electrical charge is maintained by billions of neurons. Neurons are electrically charged (or "polarized") by membrane transport proteins that pump ions across their membranes. Neurons are constantly exchanging ions with the extracellular milieu, for example to maintain resting potential and to propagate action potentials. Ions of similar charge repel each other, and when many ions are pushed out of many neurons at the same time, they can push their neighbours, who push their neighbours, and so on, in a wave. This process is known as volume conduction. When the wave of ions reaches the electrodes on the scalp, they can push or pull electrons on the metal on the electrodes. Since metal conducts the push and pull of electrons easily, the difference in push or pull voltages between any two electrodes can be measured by a voltmeter. Recording these voltages over time gives us the EEG.[5] The electric potential generated by single neuron is far too small to be picked up by EEG or MEG.[6] EEG activity therefore always reflects the summation of the synchronous activity of thousands or millions of neurons that have similar spatial orientation. If the cells do not have similar spatial orientation, their ions do not line up and create waves to be detected. Pyramidal neurons of the cortex are thought to produce the most EEG signal because they are well-aligned and fire together. Because voltage fields fall off with the square of distance, activity from deep sources is more difficult to detect than currents near the skull.[7] Scalp EEG activity shows oscillations at a variety of frequencies. Several of these oscillations have characteristic frequency ranges, spatial distributions and are associated with different states of brain functioning (e.g., waking and the various sleep stages). These oscillations represent synchronized activity over a network of neurons. The neuronal networks underlying some of these oscillations are understood (e.g., the thalamocortical resonance underlying sleep spindles), while many others are not (e.g., the system that generates the posterior basic rhythm).

WAVE PATTERNS:
Delta waves: Delta is the frequency range up to 4 Hz. It tends to be the highest in amplitude and the slowest waves. It is seen normally in adults in slow wave sleep. It is also seen normally in babies. It may occur focally with subcortical lesions and in general distribution with diffuse lesions, metabolic encephalopathy hydrocephalus or deep midline lesions. It is usually most prominent frontally in adults (e.g. FIRDA Frontal Intermittent Rhythmic Delta) and posteriorly in children (e.g. OIRDA Occipital Intermittent Rhythmic Delta).

Theta waves: Theta is the frequency range from 4 Hz to 7 Hz. Theta is seen normally in young children. It may be seen in drowsiness or arousal in older children and adults; it can also be seen in meditation.[38] Excess theta for age represents abnormal activity. It can be seen as a focal disturbance in focal subcortical lesions; it can be seen in generalized distribution in diffuse disorder or metabolic encephalopathy or deep midline disorders or some instances of hydrocephalus. On the contrary this range has been associated with reports of relaxed, meditative, and creative states.

Alpha waves: Alpha is the frequency range from 8 Hz to 12 Hz. Hans Berger named the first rhythmic EEG activity he saw as the "alpha wave". This was the "posterior basic rhythm" (also called the "posterior dominant rhythm" or the "posterior alpha rhythm"), seen in the posterior regions of the head on both sides, higher in amplitude on the dominant side. It emerges with closing of the eyes and with relaxation, and attenuates with eye opening or mental exertion. The posterior basic rhythm is actually slower than 8 Hz in young children (therefore technically in the theta range). In addition to the posterior basic rhythm, there are other normal alpha rhythms such as the mu rhythm (alpha activity in the contralateral sensory and motor cortical areas that emerges when the hands and arms are idle; and the "third rhythm" (alpha activity in the temporal or frontal lobes).[39][40] Alpha can be abnormal; for example, an EEG that has diffuse alpha occurring in coma and is not responsive to external stimuli is referred to as "alpha coma".

Beta waves: Beta is the frequency range from 12 Hz to about 30 Hz. It is seen usually on both sides in symmetrical distribution and is most evident frontally. Beta activity is closely linked to motor behavior and is generally attenuated during active movements.[41] Low amplitude beta with multiple and varying frequencies is often associated with active, busy or anxious thinking and active concentration. Rhythmic beta with a dominant set of frequencies is associated with various pathologies and drug effects, especially benzodiazepines. It may be absent or reduced in areas of cortical damage. It is the dominant rhythm in patients who are alert or anxious or who have their eyes open.

Gamma waves: Gamma is the frequency range approximately 30100 Hz. Gamma rhythms are thought to represent binding of different populations of neurons together into a network for the purpose of carrying out a certain cognitive or motor function.

Mu ranges 813 Hz., and partly overlaps with other frequencies. It reflects the synchronous firing of motor neurons in rest state. Mu suppression is thought to reflect motor mirror neuron systems, because when an action is observed, the pattern extinguishes, possibly because of the normal neuronal system and the mirror neuron system "go out of sync", and interfere with each other. "Ultra-slow" or "near-DC" (Direct current) activity is recorded using DC amplifiers in some research contexts. It is not typically recorded in a clinical context because the signal at these frequencies is susceptible to a number of artifacts.Some features of the EEG are transient rather than rhythmic. Spikes and sharp waves may represent seizure activity orinterictal activity in individuals with epilepsy or a predisposition toward epilepsy. Other transient features are normal: vertex waves and sleep spindles are seen in normal sleep. Note that there are types of activity that are statistically uncommon, but not associated with dysfunction or disease. These are often referred to as "normal variants." The mu rhythm is an example of a normal variant. The normal Electroencephalography (EEG) varies by age. The neonatal EEG is quite different from the adult EEG. The EEG in childhood generally has slower frequency oscillations than the adult EEG. The normal EEG also varies depending on state. The EEG is used along with other measurements (EOG, EMG) to define sleep stages in polysomnography. Stage I sleep (equivalent to drowsiness in some systems) appears on the EEG as drop-out of the posterior basic rhythm. There can be an increase in theta frequencies.

Santamaria and Chiappa cataloged a number of the variety of patterns associated with drowsiness. Stage II sleep is characterized by sleep spindlestransient runs of rhythmic activity in the 1214 Hz range (sometimes referred to as the "sigma" band) that have a frontal-central maximum. Most of the activity in Stage II is in the 36 Hz range. Stage III and IV sleep are defined by the presence of delta frequencies and are often referred to collectively as "slow-wave sleep." Stages I-IV comprise non-REM (or "NREM") sleep. The EEG in REM (rapid eye movement) sleep appears somewhat similar to the awake EEG PREPARATION FOR CHECK UP: Wash your childs hair the night before. Do not put any oil, gel, or hairspray in his or her hair. This can affect the test. Your child should take all regular medications and eat meals as usual prior to the test. On the day of the EEG, your child should NOT have any drinks or food containing caffeine such as soda, coffee, tea, or chocolate. Your child may bring any comfort items such as blankets, bottle, or pacifier. Tell your child that you will stay with him or her for the entire test. What happens during the EEG? A specially trained pediatric EEG technologist will perform the EEG test and explain each step to you and your child. Your child will be asked to lie down on a stretcher or bed. Your childs head will be measured with a measuring tape and the technologist will mark locations with a washable pencil. Small circular shaped electrodes are placed on your childs scalp using removable glue. The electrodes are connected to the EEG machine that records brain waves and has a video camera. The lights in the room will be turned off during part of the test to encourage sleep. A flashing light will be placed in front of the child during part of the test. The child may also be asked to take deep breaths for 3 minutes. The entire preparation and test will take between 1 to 2 hours. NEED OF EEG: The EEG looks at brain wave activity to assist in diagnosis and medical management of a variety of neurologic problems. Electrical activity in the brain can be different when a person is awake compared to when a person is and asleep, therefore, it is very important that your child be sleepy when you arrive for the EEG.

To optimize that the child will fall asleep during the EEG, we will ask you to sleep deprive your child the night before the test. What is sleep deprivation? Sleep deprivation is when a person does not get their regular amount of sleep. If sleep is not attained during the EEG, we will not have a complete study and you may need to reschedule another EEG. . How much sleep can my child get before the EEG? An infant or toddler: If possible, the appointment will be made around the childs naptime. One to 6 years old: Your child should receive HALF his or her regular amount of sleep. Your child should be up by 5 a.m. 7 years and older: Your child should have no more than 4 hours sleep the night before the test. All ages: DO NOT allow your child to nap, fall asleep after awakening or while riding in the car to the appointment. REQUIREMENTS: EEG machine (8/16 channels). Silver cup electrodes/metallic bridge electrodes. Electrode jelly. Rubber cap. Quiet dark comfortable room. Skin pencil & measuring tape.

Computerized EEG Machine:

Different types of brain waves in normal EEG:

Different types of brain waves in normal EEG: Rhythm Frequency (Hz) 8 13 14 - 30 57 Amplitude (uV) 50 100 20 Above 50 Recording & Location Adults, rest, eyes closed. Occipital region Adult, mental activity Frontal region Children, drowsy adult, emotional distress Occipital Children in sleep

Alpha() Beta() Theta()

Delta()

24

Above 50

PROCEDURE OF EEG RECORDING:

 A standard EEG makes use of 21 electrodes linked in various ways (Montage). Ask the subject to lie down in bed. Apply electrode according to 10/20% system. Check the impedance of the electrodes. 10 /20 % system of EEG electrode placement.

TWO TYPES OF RECORDING: Bipolar both the electrodes are at active site Bipolar montage are parasagital montage. Unipolar one electrode is active and the other is indifferent kept at ear lobe. Always watch for any abnormal muscle activity.Ask the subject to open eyes for 10 sec. then ask them to close the eyes.

9. ELECTROCARDIOGRAM(ECG)
ORIGIN OF THE HEART BEAT AND ELECTROCARDIOGRAM: Under physiological conditions, the sinoatrial (SA) node generates pacemaker impulses that spread to the right and left atria, converge on the atrioventricular (AV) node, and continue down the His bundle and bundle branches (right bundle branch or RBB and left bundle branch or LBB) to activate the ventricles. Depolarization is followed by repolarization and the sequence of depolarization activation-andcontraction repolarization repeats itself to generate rhythmical heart beats. Under abnormal conditions, ectopic foci in the atria, the AV junction, and the ventricles can usurp pacing dominance from this node and generate ectopic beats.

The wave of depolarization and repolarization described above can be mapped on the body surface by sensing electrodes placed on the extremities and the chest wall. The resultant waveform traced on graph paper is called the electrocardiogram (ECG). The ECG Graph Paper:

Horizontal axis of theECG graph paper represents time in milliseconds (ms) while the vertical axis represents amplitude or voltage in millivolts (mV). Each1-mm-division on the horizontal axis is 40 ms; each 5-mm-division is 200 ms. Two 5-mmdivisions on the vertical axis are calibrated to represent 1 mV. Despite the latter, ECG waves are commonly described by their height in mm rather than by their strength in mV. THE ECG LEADS: The heart occupies a position in the center of the thorax anda 12-lead ECG is simply a recordingof the current flux of cardiac depolarization and repolarization obtained from 12 different sites on the body surface. There are six limb leads: Lead I records from the left at a coordinate of 0o. Lead II records from the foot at a coordinate of 60o. Lead III records from the foot at a coordinate of 120o. Lead aVR records from the right shoulder at a coordinate of -150o. Lead aVL records from the left shoulder at a coordinate of -30o. Lead aVF recordsdirectly from the feet below at a coordinate of 90o. There are also six chest leads with sensing electrodes positioned horizontally around the left anterior hemi-thorax between the 4th and 5th interspaces:

 Leads V1 and V2 record the current flux over the right ventricle directly. Leads V3 and V4 record directly the electrical activities of the ventricular septum and the anterior wall of the left ventricle. Leads V5 and V6 record the current flow generated by the left ventricle directly.

Irrespective of whether it is a limb lead or chest lead, a current surging directly in the direction of the recording electrode will cause a positive deflection on the ECG; a current flowing in the direction but not directly toward the recording electrode will be registered as a positive deflection of lower amplitude; a current running at right angle to the direction of the recording electrode will cause no deflection or a biphasic deflection; a current flowing away in a direction opposite to that of the recording electrode will be registered as a negative deflection; and a current flowing away but not directly will cause a negative deflection of smaller amplitude.

Waves and Intervals on the ECG

Atrial and ventricular depolarization and repolarization are represented on the ECG as a series of waves: the P wave followed by the QRS complex and the T wave. The P Wave The first deflection is the P wave associated with right and left atrial depolarization. Wave of atrial repolarization is invisible because of low amplitude.

Normal P wave is no more than 2.5 mm (two-and-a half1-mm-divisions) tall and less than 120 ms (three 1mm-divisions) in width in any lead.

In sinus rhythm when the SA node is the pacemaker, the mean direction of atrial depolarization (the P wave axis) points downward and to the left, in the general direction of lead II within a coordinate between 15oand 75o and away from lead aVR. On this count the P wave is always positive in lead II and always negative in lead aVR during sinus rhythm. Conversely, a P wave that is positive in lead II and negative in lead aVR indicates normal P wave axis and sinus rhythm. The QRS Complex: The second wave is the QRS complex. Typically this complex has a series of 3 deflections that reflect the current associated with right and left ventricular depolarization. By convention the first deflection in the complex, if it is negative, is called a Q wave. The first positive deflection in the complex is called an R wave. A negative deflection after an R wave is called an S wave. A second positive deflection after the S wave, if there is one, is called the R wave. Some QRS

complexes do not have all three deflections. But irrespective of the number of waves present, they are all QRS complexes:

A QRS complex with QRS deflections:

A QRS complex with QR deflections:

A QRS complex with RS deflections:

A QRS complex with only an R wave:

A QRS complex with RSR deflections:

A QRS complex with a QS wave:

(NB: The first wave of the last complex is a negative deflection. Therefore, it qualifies to be called a Q wave. Since all QRS complexes have an R wave, there must be one in this example as well, although it may be so small that it is not visible. A negative deflection following an R wave is an S wave. Hence this single negative deflection deserves to be called a QS wave.)

QRS duration is the width of that complex from beginning to end, irrespective of the number of deflections present. Normally it lasts no more than 120 ms (three 1-mm-divisions).

The T Wave: The T wave represents the current of rapid phase 3 ventricular repolarization (see diagram above). The polarity of this wave normally follows that of the main QRS deflection in any lead. The ventricles are electrically unstable during that period of repolarization extending from the peak of the T wave to its initial downslope. A stimulus (e.g. a run away heart beat called a premature beat) falling on this vulnerable period has the potential to precipitate ventricular fibrillation: the so call R-on-T phenomenon. The PR Interval: The PR interval extends from the beginning of the P wave to the beginning of the QRS, whatever the first wave of this complex may be. This interval measures the time from the initial depolarization of the atria to the initial depolarization of the ventricles and reflects a physiological delay in AV conduction imposed by the AV node. Normal range is 120 200 ms (3 to 5 1-mm-divisions) and no longer.

The QT Interval: The QT interval is measured from the beginning of the QRS to the end of the T wave. It represents the time in which the ventricles depolarize and repolarize and is a measure of ventricular action potential (AP) duration.

This interval should be determined in the ECG lead where it is longest. Normal intervals are < 460 ms for women and < 450 ms for men. But QT values are heart-rate dependent and can vary from 270 ms at a heart rate of 150 beats/min to 500 ms at a heart rate of 40 beats/min. Corrected QT interval (QTc), obtained by dividing the measured QT interval by the square root of the RR interval, can be used in place of raw QT interval. Normal QTc is 440 ms or less.

Interpretation of the Electrocardiogram: A systematic approach to reading the 12-lead ECG should be practised so as to avoid missing data and making mistakes. The following or similar approach is advised: Check these data (patients name, birthday, and identification number; date and time of tracing)on the ECG to make sure: It belongs to the patient you are reviewing. It was obtained on the day and time you requested the examination.

Review the patients medical history, physical and laboratory findings, diagnosis, and indication of the ECG examination. These pieces of information help to focus your attention when reviewing the tracing. However, to focus attention does not mean developing tunnel vision. You still should review all aspects of the ECG before drawing your conclusion. Make old tracings available for comparison. In medical practice, changes in findings over time are as important as the presence or absence of findings at any discrete moment in time. Check heart rate. Check rhythm Primary rhythm: supraventricular (sinus, atrial, junctional) or ventricular in origin. Superimposed abnormalities (escape or premature beats). Heart Rate: Heart rate of a normal adult patient at rest is between 60 and 100 beats/min. A heart rate slower than 60 beats/min is called bradycardia; a heart rate faster than 100 beats/min is called tachycardia. To determine the heart rate from a recording made by modern ECG machines is relatively simple. These machines make a 12lead ECG tracing over a 10-second period. One row starts with lead I, switches to aVR to be followed by V1, and ends with V4. A second row starts with lead II and records aVL, V2, and V5 in sequence while a third row records lead III, aVF, V3, and V6 in sequence. Nearly all machines offer continuous recording of lead II in a fourth row and some others offer even more. Despite lead-switching in mid-course, recording is continuous without interruption over the 10-second period. Therefore heart rate per minute can be determined by counting the number of beats on any one row and multiplying this number by 6. Check heart blocks. Check QRS axis. Check signs of clinical abnormalities: Right and left atrial abnormalities. Right and left ventricular hypertrophy. Right and left bundle branch block. Acute myocardial infarction. Electrolyte abnormalities. Drug effects. Pulmonary embolism.

A second method of determining heart rate is shown below:

The heart rate is 300 beats/min when 2 consecutive QRS complexes are one 5-mm-division (200 ms) apart. By the same token, the heart rates are 150, 100, 75, 60, and 50 beats/min when 2 consecutive QRS complexes are two, three, four, five, and six 5-mmdivisions (400, 600, 800, 1000, 1200 ms) apart respectively. If the distance between 2 consecutive QRS complexes does not equal to a whole number of 5-mm-divisions, a rough estimate of the heart rate will have to be made as shown in the tracing. This method is particularly useful in determining heart rates at different times in a tracing in which the rhythm is irregular:

A third method applies to single-lead rhythm strips printed from ECG monitors in critical care areas:

These rhythm strips have 3-second marks and heart rate is a matter of multiplying the number of QRS complexes in a 6-second period by 10. For very slow heart rates in which there are few QRS complexes in a 6-second interval, accuracy can be improved by multiplying the number of QRS complexes in a 12-second period by 5. Rhythm: Normal cardiac rhythm arises from the SA node (sinus rhythm) but pacemaker impulses can come from ectopic foci in the atria, the AV junction, and the ventricles under abnormal conditions. When an ectopic impulse occurs singly, it generates a beat; when the beat repeats itself, it becomes a rhythm. In addition, ectopic impulses can arise through an escape mechanism or through prematurely. Each of these terms is explained in the sections that follow.

Sinus Rhythm: Sinus rhythm implies that the SA node is the pacemaker and normal sinus rhythm (NSR) is simply sinus rhythm with heart rate in the normal range of 60 100 beats/min. The P waves in sinus rhythm have normal axis and are positive in lead II and negative in lead aVR. The QRS width in sinus rhythm is normal because the ventricles are activated rapidly by impulses conducted down the His bundle and bundle branches. Sinus rhythm is regular with the exception of a phenomenon called sinus arrhythmia during which there is a minimal increase in heart rate during inspiration and a minimal decrease in heart rate duringexpiration. Although arrhythmia means abnormal cardiac rhythm, sinus arrhythmia is truthfully not an abnormal rhythm. Sinus Pause or Arrest

In disease (e.g. sick sinus syndrome) the SA node can fail in its pacing function. If failure is brief and recovery is prompt, the result is only a missed beat (sinus pause). If recovery is delayed and no other focus assumes pacing function, cardiac arrest follows. Escape rhythms: An escape beat is a heart beat arising from an ectopic focus in the atria, the AV junction, or the ventricles when the sinus node fails in its role as a pacemaker or when the sinus impulse fails to be conducted to the ventricles as in complete heart block (see section on Heart Blocks below). The ectopic impulse in this instance is always late, appearing only after the next anticipated sinus beat fails to materialize. If the sinus node failure or heart block is only brief, the ectopic focus may generate only a single escape beat; if the sinus node failure or heart block is prolonged, the ectopic focus produces a rhythm of escape beats to assume full pacing function. This escape mechanism offers protection against total cardiac standstill in the event of sinus node failure or complete heart block.

Atria Escape

Atria escape, either in escape beat or escape rhythm, produces a P wave that has abnormal axis and looks different from the P wave produced by the sinus beat. However, depolarization spreads to the ventricles normally down the AV junction, the His bundle, and bundle branches. Therefore the QRS complex of the atrial escape beats looks exactly like the QRS complex of the sinus beat. The inherent rate of atrial escape rhythm is between 60 and 80 beats/min. Junctional Escape:

In junctional (AV junctional) beat or rhythm the atrial depolarization current points cephalad and to the right, away from lead II and toward lead aVR. Therefore the P wave, if seen, would be negative in lead II and positive in lead aVR. However this P wave is usually buried by the QRS complex and not visible. On less common occasions when the P wave is visible, it may be either immediately before or immediately after the QRS complex. Since the impulse is conducted to the ventricles via the His bundle and bundle branches, the QRS complex of junctional beats is narrow and looks exactly like the QRS complex of the sinus beat. The inherent rate of junctional escape rhythm is 40 60 beats/min.

Conceptually the visibility and position of the P wave in junctional beat or rhythm can be explained as follows: If the ectopic junctional focus is in the center of the node, the depolarization impulse has to travel an equal distance up and down the node to depolarize the atria and the ventricles. Hence activation of atria and ventricles is simultaneous (conduction down the His bundle and bundle branch is very fast) and the P wave is buried within the QRS complex.

If the ectopic focus is high up in the AV node, the depolarization wave reaches the atria before the ventricles and atrial activation precedes ventricular activation. As a result, the P wave is in front of the QRS complex.

If the ectopic focus is low down in the AV node, ventricular activation precedes atrial activation and the P wave follows the QRS complex.

Ventricular Escape: In ventricular escape beat or rhythm, the depolarization wave spreads slowly via abnormal pathway in the ventricular myocardium and not via the His bundle and bundle branches. Therefore, the QRS complex is wide (>120 ms) and has a shape different from that of the sinus beat.

If the ventricular escape rhythm is the result of sinus node failure, no P wave of atrial contraction is seen as in the tracing above. If the ventricular escape rhythm is the result of 3rd degree (complete) heart block, the sinus node paces the atria independently and regular P waves unrelated to the ventricular escape beats can be seen. The inherent rate of ventricular escape rhythm is between 20 and 40 beats/min.

10.ULTRASONOGRAPHY

ULTRASONOGRAPHY In todays veterinary practice, the use of Ultrasonography (US) is becoming much more common place. In the past, US has only been available in larger practices or universities. As owners are now well aware of US, they often expect it will be available for their pet. US is non-invasive and does not use radiation so its quite safe. STRENGTHS OF ULTRASONOGRAPHY Determining origin of an abdominal mass on radiographs, it may not be definitive which organ is affected Evaluation of organ parenchyma Liver, spleen, kidneys, adrenals, pancreas, intestines, prostate, bladder, heart radiographs just provide an image of the silhouette of the organ US lets you see inside Fetal viability heart beats of the fetus can be seen with US Real time scanning see movement/motion this is great for hearts, like to evaluate contractility in a dilated cardiomyopathy case, or see the left ventricle in action in a hypertrophic cardiomyopathy kitty. Intestinal peristalsis can also be evaluated. Performing fine needle aspiration/ biopsy Cells or tissue NOT images ultimately give us the definitive diagnosis for neoplasia, etc. Ultrasound does not provide a histopathologic diagnosis different diseases can appear very similar on US so a FNA or biopsy might be needed. WEAKNESSES OF ULTRASONOGRAPHY Ultrasound cant penetrate gas or bone lungs, free air in abdomen, ribs etc make evaluation difficult we can use gas and bone however to diagnose things such as cystic calculi Difficult to evaluate liver size, kidney size in dogs size is subjective on US Cant assess intestinal gas patterns Cant evaluate some extra abdominal structures (i.e. spine) Equipment can be expensive though this is becoming much less of an issue Diagnostic success is user dependent trash in = trash out. It takes a long time to become proficient at US. A weekend course using someone elses machine wont cut it. You must know how to use YOUR machine. The best option in my opinion is to get a radiologist to work with you on your machine to become comfortable.

Also it would be useful to select a person you could send CDs to which are in movie mode for a specialist to view. This way they can help you improve your scanning and also aid in the diagnosis. Interpretation often is best left to a very experienced sonographer. Must know anatomy very well it is again looking at anatomy in a different light essentially cross sectionally. Basic Ultrasound Physics Transducer (probe) produces the ultrasound beam Piezoelectric crystal Emit sound after electric charge applied Sound reflected from patient Returning echo is converted to electric signal- grayscale image on monitor Echo may be reflected, transmitted, or refracted Transmit 1% receive 99% of the time Acoustic Impedance The velocity of sound in a tissue and tissue density = determine acoustic impedance acoustic impedance allows differentiation of separate structures in an US image. This is because different soft tissues for example have slightly different acoustic impedances. Most soft tissues = 1400-1600m/sec Bone = 4080, Air = 330 Sound will not penetrate gets reflected or absorbed Travel time dot depth the time interval between transmission of the sound beam and the reception of the echo that returns Attenuation = removal of energy from the sound wave as it travels through tissue. Absorption = energy is captured by the tissue then converted to heat Reflection = occurs at interfaces between tissues of different acoustic properties Scattering = beam hits irregular interface beam gets scattered Basic Ultrasound Physics Sound waves are measured in Hertz (Hz) Diagnostic ultrasound typically 1-20 MHz As frequency increases, resolution improves As frequency increases, depth of penetration decreases Transducers

Sector scanner fan shaped beam Small surface require for contact Linear scanner rectangle beam Large contact area required New ones are curvi-linear These scan heads are much smaller with wide field of view Basic Ultrasound Physics Monitor and computer many now are the size of a lap top computer and many use the windows XP platform Convert signal to an image/ archive Tools for image manipulation Gain amplification of returning echoes Overall brightness this is usually a single knob Time gain compensation (curve) Adjust brightness at different depths this is usually multiple structures placed in a slide fashion I usually place mine on a diagonal. The curve can be seen on the monitor image along the side. Freeze Depth Zoom in superficial, or zoom out for wide view Depth limited by frequency Focal zone Optimal resolution wherever focal zone is Modes of Display A mode Spikes where precise length and depth measurements are needed ophtho B mode (brightness) used most often 2 D reconstruction of the image slice M mode motion mode function of time on a horizontal axis Moving 1D image cardiac mainly Doppler used to identify the presence or absence of flow. The direction and velocity of flow can be visualized and calculated and turbulence can also be seen.

ARTIFACTS Improper machine settings gain Excessive TGC can result in an acceptable image in the far field but the near field will be too bright. Inadequate TGC can result in an acceptable image in the near field but the far field will be too dark. Reverberation time delays due to bouncing back and forth Mirror image liver diaphragm GB when echoes bounce back and forth between 2 interfaces the return to the transducer time is extended. Therefore, a second image of the structure is placed deeper than it really is. Comet tail gas bubble multiple bright streaks/bands deep to the reflective structure Ring down skin transducer surface Acoustic shadowing failure of the US beam to pass through an object because of reflection and or absorption of the beam. See a black area beyond the surface of the reflector. Bone, cystic calculus, lung. Acoustic enhancement Edge enhancement Border of kidney ULTRASOUND TERMINOLOGY Never use dense, opaque, lucent Anechoic No returning echoes= black (acellular fluid) Echogenic high or low can be use to qualify Regarding fluid--some shade of grey d/t returning echoes Echogenicity can also be called mixed if both white and dark areas are noted. Relative terms Comparison to normal echogenicity of the same organ or other structure * Hypoechoic = a structure which is of low echogenicity - it will appear blacker * Isoechoic = structure which is of equal echogencity * Hyperechoic = a structure which is of higher echogencity it will appear whiter. Spleen should be hyperechoic to liver Describing findings in terms of focal or diffuse, echogenicity, size, shape, margination and position should be used.

PATIENT POSITIONING PREPARATION

If the stomach or GIT is of interest, withholding food for 12 hours might be useful. Placing water in the stomach can help visualize the stomach wall and pancreas area just before the exam. Gas in the GIT can be very annoying and can limit visualization of abdominal organs. It is best to view the bladder under moderate distension. If the bladder is empty, a mass can be missed. If sedation is needed to perform the US exam, it should be noted than GI transit for example can be altered. Dorsal recumbency this is the way I prefer to scan it is very similar anatomy wise to performing surgery from a ventral approach Lateral recumbency can be used if the patient is having difficulty breathing Standing large dogs like Danes that are hard to place on their backs. Urinary bladder calculi can also be imaged this way as well to see if they are gravity dependent Clip hair Be sure to check with owners (show animals) the US beam cannot penetrate air and air gets trapped in the hair of the patient. Apply ultrasound gel acoustic coupling gel Alcohol can be used esp. in horses Image Orientation and Labeling Must be consistent so if you scan the animal one time and on recheck someone else scans they can look at your images and know what you saw. Symbol on screen ~ dot on transducer dot to head and dot to patients right dot lateral for transverse and proximal for longitudinal images of limbs For distance use from the accessory carpal or calcaneal bones such as lesion located 5 cm distal to the ACB Label label label Indications for Abdominal Ultrasonography Same as with abdominal radiographs Should have some idea of what you are looking fornot just a fishing expedition Further investigate a radiographic finding ***If clinical signs or history indicate abdominal ultrasound, then it should be performed even if radiographs are normal!!! Ultrasound-guided FNA/ biopsies NORMAL ABD U/S FINDINGS DO NOT MEAN ORGANS ARE NORMAL!!!

Do FNA if suspect disease Abnormal u/s findings nonspecific Benign and malignant masses identical Bright liver may be secondary to Cushings disease or lymphoma Aspirate abnormal structures (with few exceptions)!!! Obtain owner approval prior to exam Warn owner of risks +/- Clotting profile Risks of FNAs Fatal hemorrhage Pneumothorax w/ pulmonary masses Seeding of tumors TCC Sepsis Abscesses I Routinely aspirate Liver (masses and diffuse disease) Spleen (nodules and diffuse disease) Gastrointestinal masses Enlarged lymph nodes Enlarged prostate Pulmonary/ mediastinal masses (usually dont biopsy due to risk of pneumothorax I Occasionally aspirate Kidneys (esp. if enlarged) Pancreas Urinary bladder masses I Never aspirate Adrenals Gall bladder Non-aspiration Technique 22g 1.5in needle 6 cc syringe Short jabs into organ Spray onto slide, smear, and check abd for hemorrhage Aspiration technique Same set up as with non-aspiration technique With needle in structure, pull back plunger vigorously several times Remove needle, fill syringe with air Spray onto slide and smear Ultrasound-guided Core Biopsies

Use a special biopsy gun 14-20g Insert thru small skin incision Much more representative sample Tissue not just cells Sometimes it is necessary to get the answer MUCH MORE LIKELY TO BLEED! COMMON APPLICATIONS OF ABDOMINAL ULTRASONOGRAPHY Liver Nodules, masses, cysts Infiltrative disease Lymphoma Diffuse dz Hepatitis Biliary obstruction Portosystemic shunts Spleen Nodules, masses, hematomas Infiltrative disease Splenic hemangiosarcoma, hematoma, and nodular hyperplasia all look alike! Pancreas Pancreatitis Masses, cysts Gastrointestinal tract May be limited by gas, ingesta, feces Dilation Motility Masses Intussusceptions Inflammatory/ infiltrative dz Adrenals Adrenomegaly Bilateral vs. unilateral enlargement Masses

Kidneys

Chronic renal disease Infarcts Hydronephrosis/ pyelectasia Pyelonephritis Calculi PKD Urinary bladder Cystitis Neoplasia Calculi All types are visible Reproductive tract Pregnancy (fetal viability), pyometra Ovarian/ testicular masses Prostatic disease Hyperplasia Neoplasia Prostatitis/ abscesses Prostatic/ paraprostatic cysts Lymph nodes Lymphoma, metastasis, reactive nodes Mesenteric Aortic Sublumbar (medial iliac, hypogastric) Organ specific nodes Peritoneum Abdominocentesis with small volumes Echocardiography Contractility, chamber size, wall thickness Septal defect and other anomalies Valvular abnormalities Pericardial effusion/ pericardiocentesis Heart base, myocardial tumors

Non-cardiac Thoracic Ultrasonography

Mediastinal masses Pulmonary/ pleural masses Diaphragmatic hernia Thoracocentesis for small volume pleural effusion Head Ocular Cataracts Retinal detachment Intraocular masses Retrobulbar masses Brain If have open fontanelle Hydrocephalus Neck Thyroid and parathyroid gland Adenomas, adenocarcinomas Carotid a. and jugular v.