DIAGNOSTIC TEST and PROCEDURES NON INVASIVE DIAGNOSTIC TEST I.

. ELECTROCARDIOGRAM : ECG / EKG Type of test : ELECTRODIAGNOSTIC NORMAL FINDINGS : Normal heart rate (60-100 beats/min), rhythm and wave deflections. ELECTROCARDIOGRAPH An electrocardiograph (ECG or EKG) records the electrical activity of the heart. Preceding each contraction of the heart muscle is an electrical impulse generated in the sinoatrial node; the waves displayed in an ECG trace the path of that impulse as it spreads through the heart. Irregularities in an ECG help physicians diagnose coronary heart disease and other disorders in the muscle, blood supply, or neural control of the heart. Test explanation o Electrical impulses are conducted to the bodys surface o Detected by electrodes placed on the patients limbs and chest o Electrodes detect the electrical activity of the heart from a variety of spatial perspective

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Each combination of electrodes is called ELECTRODES

PROCEDURE AND PATIENT CARE BEFORE Explain the procedure to the patient Tell the patient that no food of fluid restriction is necessary. Document any cardiac medications that the client is taking Assure the patient that the flow of electric current is from the patient. He or she will feel nothing during this procedure. Expose only the patients chest and arms. Keep the abdomen and thighs adequately covered. DURING Skin Areas Designated For Electrode Placement Are Prepared. Instruct To Lie Still Without Talking. Electrode Paste Is Applied. To Ensure Electrical Conduction Between The Skin And Electrodes. Leads Are Positioned As Follows V1 : 4TH ICS at the Right sternal border V2 : 4TH ICS at the Left sternal border V3 : MIDWAY between V2 and V4 V4 : 5TH ICS at the midclavicular line V5 : at the Left Anterior Axillary line at the level of V4 horizontally V6 : at the Left Midaxillary line on the level of V4 horizontally AFTER Remove Electrodes And Wipe Off The Gel Indicate On The Ekg Strip If The Patient Was Experiencing Chest Pain During The Study. Procedure Takes In Less Than 5 Minutes

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P wave- depolarization of the atria. Duration is 0.04 to 0.11 secs. PR interval- time of impulse transmission from the sinoatrial node to atrioventricular node. Duration is 0.12-0.20 secs. QRS complex- depolarization of the ventricles. Duration is 0.05-0.10 secs. ST segment- re[resents the plateau phase of the action potential. T wave- ventricular repolarization. Should not exceed 5 mm amplitude.

Image showing a patient connected to the 10 electrodes necessary for a 12-lead ECG
II. ECHOCARDIOGRAPH : CARDIAC ECHO AND HEART SONOGRAM Type of test : Ultrasound Normal findings : Normal position, size and movement of the cardiac valves and heart muscle wall. Test explanation : o Normal directional flow of blood within the heart chambers. o A high-frequency sound waves are emitted from a transducer that penetrates the heart o Sound waves are bounced back off the heart and reflected back to the transducer as a series of echo

BEFORE Assure The Patient That This Is Painless Study

DURING Placed The Patient In Supine Position EKG Leads Are Placed A Gel Is Placed On The Chest Wall Immediately Under The Transducer. Allows Better Transmission Of Sound. UTZ Are Directed To The Heart And Appropriate Tracings Are Obtained Tell That No Discomfort Is Associated. Gel Is Usually Cooler Than Body Temperature. AFTER Remove The Gel From The Patients Chest Wall Inform The Patient That The Physician Will Interpret The Study And That The Results Will Be Available In A Few Hours. Procedure Usually Approximately Takes 45 Minutes

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III. CHEST X-RAY : CXR, Chest Radiography Type of test : X-ray, Radiologic exam Normal findings : Normal lungs and surrounding structures X-rays are electromagnetic radiation of a very short wavelengths commonly generated by passing a current of high voltage that can penetrate most substances by strongly ionizing the tissue which they pass. o Show the size and shape of the heart and outline blood vessels in the lungs and chest o 4 densities of substances on radiographs : Air = blackish Fat = dark gray Water = lighter gray Bone whitish Information provided by the CXR o Tumors of the lungs, heart, chest wall and bony thorax o Inflammation of the lung, pleura and pericardium o Fluid accumulation in the pleura, pericardium and lung o Fx of the bones of the thorax o Diaphragmatic hernia Test explanation & related physiology

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Most are taken at a distance of 6 feet with patient standing Can also be used in sitting or supine position Techniques / View : PA (Postero-anterior) view = back to the front Lateral view = at the side Oblique view = slanted with at different angles as they pass through the body

Lordotic view = provide visualization of the apices (rounded upper portions) of the lungs. Usually used for detection of TB Decubitus view = patient at recumbent lateral position to localize fluid in the pleural space (pleural effusion).

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BEFORE Explain the procedure to the patient Tell the patient that no fasting is required Instruct to remove clothing to the waist and put on an x-ray gown Inform to remove ALL METAL objects. So they do not block visualization of part of the chest. Tell to take a deep breath and hold it while the X-ray films are taken. DURING After correctly positioned, tell to take a deep breath and hold it until the X-ray films are taken Inform that no discomfort is associated with chest radiography AFTER Note that no special care is required following the procedure X-ray films are taken by a radiologic technologist in several minutes

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Image A: A normal chest radiograph. Image B: fever pneumonia.

IV. RADIONUCLIDE STUDIES Synonym(s) o isotope scan o nuclear medicine imaging procedure o radioisotope study o radionuclide scanning o RI scan o scintigraphy Process whereby a radionuclide is injected or measured (through tissue) from an external source, and a display is obtained from any one of several rectilinear scanner or gamma camera systems. The image obtained from a moving detector is called a scan, while the image obtained from a stationary camera device is called a scintiphotograph. A test that produces pictures (scans) of internal parts of the body. The person is given an injection or swallows a small amount of radioactive material; a machine called a scanner then measures the radioactivity in certain organs. Radionuclide imaging uses a special detector (gamma camera) to create an image following injection of radioactive material. This test is done to evaluate coronary artery disease (CAD), valvular or congenital cardiac disorders, cardiomyopathy, and other cardiac disorders. Radionuclide imaging exposes patients to less radiation than do comparable x-ray studies. However, because the radioactive material is retained in the patient briefly, sophisticated radiation alarms (eg, in airports) may be triggered by the patient for several days following such testing. SPECT in Recent-Onset Angina

Planar techniques, which produce a 2-dimensional image, are rarely used; SPECT, which uses a rotating camera system and tomographic reconstruction to produce a 3-dimensional image, is more common in the US. With multihead SPECT systems, imaging can often be completed in 10 min. Visual comparison of stress and delayed images can be supplemented by quantitative displays. With SPECT, inferior and posterior abnormalities and small areas of infarction and the vessels responsible for infarction can be identified. The mass of infarcted and viable myocardium can be quantified, helping determine prognosis. These imaging scans use radioactive materials called radiopharmaceuticals or radiotracers. Depending on the type of nuclear medicine exam you are undergoing, the radiotracer is either injected into a vein, swallowed or inhaled as a gas and eventually accumulates in the organ or area of your body being examined, where it gives off energy in the form of gamma rays. This energy is detected by a device called a gamma camera, a (positron emission tomography) PET scanner and/or probe. These devices work together with a computer to measure the amount of radiotracer absorbed by your body and to produce special pictures offering details on both the structure and function of organs and tissues.

In some centers, nuclear medicine images can be superimposed with computed tomography (CT) or magnetic resonance imaging(MRI) to produce special views, a practice known as image fusion or co-registration. These views allow the information from two different studies to be correlated and interpreted on one image, leading to more precise information and accurate diagnoses. In addition, manufacturers are now making single photon emission computed tomography/computed tomography (SPECT/CT) and positron emission tomography/computed tomography (PET/CT) units that are able to perform both imaging studies at the same time. Nuclear medicine also offers therapeutic procedures such as radioactive iodine (I-131) therapy that uses radioactive material to treat cancer and other medical conditions affecting the thyroid gland. Test explanation Nuclear medicine imaging scans are performed to: analyze kidney function.

visualize heart blood flow and function (such as a myocardial perfusion scan). scan lungs for respiratory and blood flow problems. identify inflammation in the gallbladder. evaluate bones for fractures, infection, arthritis and tumors. determine the presence or spread of cancer in various parts of the body. identify bleeding into the bowel. locate the presence of infection. measure thyroid function to detect an overactive or underactive thyroid. investigate abnormalities in the brain, such as seizures, memory loss and abnormalities in blood flow. localize the lymph nodes before surgery in patients with breast cancer or melanoma.

In children, nuclear medicine is also used to: investigate abnormalities in the esophagus, kidneys and intestines.

evaluate the openness of tear ducts and shunts in the brain and heart.

Nuclear medicine therapies include: Radioactive iodine (I-131) therapy used to treat hyperthyroidism (overactive thyroid gland, for example, Graves' disease) and thyroid cancer. Radioactive antibodies used to treat certain forms of lymphoma (cancer of the lymphatic system).

I-131 MIBG (radioactive iodine laced with metaiodobenzylguanidine) used to treat adrenal gland tumors in adults and nerve tissue tumors in children. Most nuclear medicine procedures are performed using a gamma camera, a specialized camera encased in metal that is capable of detecting radiation and taking pictures from different angles. It may be suspended over the examination table or it may be beneath the table. Often, gamma cameras are dual-headed with one camera above and one camera beneath the table. The camera could also be located within a large, doughnut-shaped scanner similar in appearance to a computed tomography (CT) scanner. In some imaging centers, the gamma camera is located beneath the exam table and out of view. Some cameras can rotate around the body and produce more detailed images, referred to as Single Photon Emission Computed Tomography (SPECT). A positron emission tomography (PET) scanner is a large machine with a round, doughnut shaped hole in the middle, similar to a CT or MRI unit. Within this machine are multiple rings of detectors that record the emission of energy from the radiotracer in your body. A computer aids in creating the images from the data obtained by the camera or scanner.

Radioactive phosphorus (P-32) used to treat certain blood disorders. Radioactive materials used to treat painful tumor metastases to the bones.

A probe is a small hand-held device resembling a microphone that can detect and measure the amount of the radiotracer in a small area of your body. There is no specialized equipment used during radioactive iodine therapy, but the technologist or other personnel administering the treatment may cover your clothing and use lead containers to shield the radioactive material you will be receiving.

BEFORE *You should inform your physician and the technologist performing your exam of any medications you are taking, including vitamins and herbal supplements. You should also inform them if you have any allergies and about recent illnesses or other medical conditions. *Jewelry and other metallic accessories should be left at home if possible, or removed prior to the exam because they may interfere with the procedure.

DURING * You will be positioned on an examination table. If necessary, a nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm. Depending on the type of nuclear medicine exam you are undergoing, the dose of radiotracer is then injected intravenously, swallowed or inhaled as a gas. It can take anywhere from several seconds to several days for the radiotracer to travel through your body and accumulate in the organ or area being studied. *As a result, imaging may be done immediately, a few hours later, or even several days after you have received the radioactive material. When it is time for the imaging to begin, the gamma camera will take a series of images. The camera may rotate around you or it may stay in one position and you will be asked to change positions in between images. While the camera is taking pictures, you will need to remain still for brief periods of time. In some cases, the camera may move very close to your body. This is necessary to obtain the best quality images. * If you are claustrophobic, you should inform the technologist before your exam begins. If a probe is used, this small hand-held device will be passed over the area of the body being studied to measure levels of radioactivity. Other nuclear medicine tests measure radioactivity levels in blood, urine or breath. The length of time for nuclear medicine procedures varies greatly, depending on the type of exam. Actual scanning time for nuclear imaging exams can take from 20 minutes to several hours and may be conducted over several days.

*Young children may require gentle wrapping or sedation to help them hold still. If your doctor feels sedation is needed for your child, you will receive specific instructions regarding when and if you can feed your child on the day of the exam. A physician or nurse specializing in the administration of sedation to children will be available during the exam to ensure your child's safety while under the effects of sedation. *If the radiotracer is given intravenously, you will feel a slight pin prick when the needle is inserted into your vein for the intravenous line. When the radioactive material is injected into your arm, you may feel a cold sensation moving up your arm, but there are generally no other side effects. *When swallowed, the radiotracer has little or no taste. When inhaled, you should feel no differently than when breathing room air or holding your breath. *With some procedures, a catheter may be placed into your bladder, which may cause temporary discomfort. It is important that you remain still while the images are being recorded. Though nuclear imaging itself causes no pain, there may be some discomfort from having to remain still or to stay in one particular position during imaging.

AFTER *When the examination is completed, you may be asked to wait until the technologist checks the images in case additional images are needed. Occasionally, more images are obtained for clarification or better visualization of certain areas or structures. The need for additional images does not necessarily mean there was a problem with the exam or that something abnormal was found, and should not be a cause of concern for you. You will not be exposed to more radiation during this process. *If you had an intravenous line inserted for the procedure, it will usually be removed unless you are scheduled for an operating room procedure that same day. If the radiotracer is given intravenously, you will feel a slight pin prick when the needle is inserted into your vein for the intravenous line. When the radioactive material is injected into your arm, you may feel a cold sensation moving up your arm, but there are generally no other side effects. When swallowed, the radiotracer has little or no taste. When inhaled, you should feel no differently than when breathing room air or holding your breath. With some procedures, a catheter may be placed into your bladder, which may cause temporary discomfort. It is important that you remain still while the images are being recorded. Though nuclear imaging itself causes no pain, there may be some discomfort from having to remain still or to stay in one particular position during imaging. Unless your physician tells you otherwise, you may resume your normal activities after your nuclear medicine scan. If any special instructions are necessary, you will be informed by a technologist, nurse or physician before you leave the nuclear medicine department. Through the natural process of radioactive decay, the small amount of radiotracer in your body will lose its radioactivity over time. It may also pass out of your body through your urine or stool during the first few hours or days following the test. You may be instructed to take special precautions after urinating, to flush the toilet twice and to wash your hands thoroughly. You should also drink plenty of water to help flush the radioactive material out of your body as instructed by the nuclear medicine personnel. INVASIVE DIAGNOSTIC TEST I. CARDIAC CATHETERIZATION : CORONARY ANGIOGRAPHY, ANGIOCARDIOGRAPHY, VENTRICULOGRAPHY Type of test : X-ray with contrast dye Normal findings : Normal heart muscle motion, normal coronary arteries, normal great vessels, and normal intracardiac pressures and volumes. Fluoroscopy-guided insertion of radiopaque catheter inserted thru peripheral blood vessel (femoral or antecubital vein) via percutaneous puncture, combined with angiography (injection of contrast material/dye) thru the catheter into the circulation Provides information about: o Oxygen saturation (saO2) of chambers and great vessels o Pressure changes o Cardiac Output (CO) and Stroke Volume (SV) o Anatomic abnormalities

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BEFORE Explain the procedure Secure informed consent Ask for hx of allergy to seafoods/iodine/dye Measure accurate height/length & weight: to determine the amount of dye WOF S/Sx of infection at site to be used

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Check for presence and quality of both pedal pulses and mark them. Facilitate postcatheterization assessment of pulses of the affected and unaffected extremities. o Get baseline VS esp. saO2 o Give analgesic/sedative as ordered o NPO 6-8 hrs pre-op o Instruct to void before giving to the catheterization laboratory o Remove all valuables and dental prostheses o Obtain IV access for delivery of IV fluids and cardiac drugs, if necessary, with IVF to prevent hypoglycemia and dehydration as ordered o Prepare the catheter insertion site by shaving and scrubbing it

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DURING The chosen catheter insertion site is prepared and draped in a sterile manner PROCEDURAL STEPS Tell patient that during the injection, he/she may experience a severe hot flush or a fluttering feeling as the catheter passes through the heart. This is extremely uncomfortable but lasts only a few seconds. NOTE : Some px have a tendency to cough as the catheter is placed into the pulmonary artery.

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WOF arrythmia during catheter insertion WOF feeling of warmth, N/V, restlessness and headache, urticaria, flushing during injection of dye Monitor VS: bradycardia, hypoTN may indicate hemorrhage or cardiac perforation

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AFTER WOF hemorrhage Maintain occlusive, water proof dressing at site Check dressing for bleeding Check site for hematoma Ensure adequate fluid intake to prevent dehydration (due to blood loss, NPO status and diuretic action of the dye) and hypoglycemia Maintain client on bed rest 6-8 hours Keep the affected extremity straight; after 1-2 hours head may be elevated <30 degrees for those who had the femoral artery as the insertion site Maintain pressure dressing at insertion site WOF thrombus formation Check equality and presence of distal pulses Check for T and color of affected extremity If (+) venospasm: warm : compress on contralateral extremity Keep affected extremity straight to facilitate healing o Venous: 4-6 hrs o Arterial: 6-8 hrs Give pain meds as ordered Test is performed by a cardiologist in approx. 1 hour and results will be available in 1-2 days

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II. LYMPANGIOGRAPHY DESCRIPTION : o Visualization of the lymphatic system can be achieved by means of injection of dye or contrast medium into the lymphatic system of an arm or leg. A dye (Evans blue) is first injected into the web of skin between the 1st and 2nd toes or between the fingers. o The blue dye is picked up by the lymphatic system is outline, and a lymphatic system. After approximately 30 mins., the lymphatic system is outlined, and a lymphatic vessel is then dissected and a small catheter inserted for the injection of an iodine dye (Ethiodol). o Radiographs are taken after the iodine dye is injected and again 24 hours later. Other X-ray pictures may be taken later because the lymph nodes retain the contrast medium for several weeks, even months. PURPOSE OF LYMPHAGIOGRAMS (LAGs) o Enlarged and diseased lymph nodes can be identified on the radiographs. The LAG can show not only the extent of the disease, such as LYMPHOMA or HODGKINs disease, but also the effectiveness of therapy. III.VENOGRAMS o PURPOSE

May be useful in detecting deep venous thrombosis (DVT) or to assess other venous abnormalities, such as congenital abnormalities or incompetent valves. Venograms show only structure and flow. Radioisotopes are sometimes injected into veins to assess for the presence of DVT.

DESCRIPTION A dye or contrast medium can be injected into a vein by means of venipuncture or cutdown to view the venous system of particular organs or to evaluate flow to a particualr area (e.g. radiographs taken as the dye goes through the venous system of the leg). Dye may be injected into a catheter in the FEMORAL vein or INFERIOR VENA CAVA, and the catheter can be threaded to various organs to inspect details in the venous supply of the organ.

Phlebography in a patient with deep venous thrombosis. IV. BONE MARROW ASPIRATION / BIOPSY : Biopsy is the removal and examination of tissue from the body Normal Findings : Normal cells and tissue from the bone marrow PURPOSE Performed when there are abnormal types of cells on a peripheral blood smear Used to confirm the presence of metastatic tumor or diseases such as Leukemia or various types of anemia. Bone marrow studies may be performed periodically to evaluate the response to treatment.

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Common sites (Adult) Posterior Iliac Crest Anterior Iliac Crest Sternum Tibia (children) TEST EXPLANATION AND PROCEDURAL STEPS : The area is prepared, and a local anesthetic is administered (sternum or iliac spine). Hair may be have to be shaved from the site. The physician or nurse practitioner inserts the needle with a stylet is inserted through a skin slit into the bone about 3mm deep until the bone marrow is reached. The stylet is removed and a 10mL syringe is attached to the needle. For aspiration, the plunger of the syringe is pulled back to withdraw a small amount of marrow into the syringe. When the plunger is pulled back, the client often feels sharp pain. The client should be carefully for this momentary pain. Normal bone marrow is soft and semi-fluid and thus, a sample can often be obtained by means of aspiration with a syringe. The specimen obtained must be carefully placed in the correct container. A blood smear may be microscopically examined immediately to make sure tiny bone particles, called SPICULES, are present and the remaining amount is placed in a green or lavender-top tube. Six or more slides maybe prepared. A culture tube may also be necessary. Usually only small adhesive dressing is placed over the site because there is minimal bleeding or drainage. A small pressure dressing is used if a biopsy was performed.

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BEFORE Secure consent Check that the prescribed lab test have been done. o A CBC with differential and reticulocyte count should be ordered on the day of biopsy. Explain the biopsy procedure Check the vital signs

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DURING Prep the area to be used. Shave the site as applicable. A local anesthetic is injected The patient is positioned, and a local anesthetic such as lidocaine is administered first under the skin with a fine needle and then around the bone at the intended puncture site with a somewhat larger gauge needle. When the area is numb, a small incision is made in the skin and the biopsy needle is inserted. Pressure is applied to force the needle through the outer bone, and a decrease in resistance signals entry into the marrow cavity. The needle most often used for bone marrow biopsy is a Jamshidi trephine needle or a Westerman-Jensen trephine needle. A syringe is placed on the top of the needle and 12 ml of the bone marrow is aspirated into the syringe. In some instances, the marrow cannot be aspirated because it is fibrosed or packed with neoplastic cells. The syringe is removed and the medical technologist uses this sample to prepare several smears containing small pieces of bone (spicules). Another syringe is fitted onto the needle hub and another sample of 3 ml is removed and transferred to a tube containing EDTA for analysis by flow cytometry, cytogenetic testing, or other special laboratory procedures. Following aspiration, the cutting blades are inserted into the hollow of the needle until they protrude into the marrow. The needle is then forced over the tips of the cutting blades and the needle is rotated as it is withdrawn from the bone. This process captures the core sample inside the needle. A wire probe is inserted at the cutting end and the bone marrow sample is pushed through the hub of the needle onto sterile gauze. The specimen is used to make several preparations on glass slides or coverglasses and is transferred to a fixative solution. *AFTER *the biopsy site is covered with a clean, dry pressure bandage. *The patient must remain lying down and is observed for bleeding for one hour. The patient's pulse, breathing, blood pressure, and temperature are monitored until they return to normal. The biopsy site should be kept covered and dry for several hours. *The patient should be able to leave the clinic and resume most normal activities immediately. Patients who have received a sedative often feel sleepy for the rest of the day; so driving, cooking, and other activities that require clear thinking and quick reactions should be avoided. Walking or prescribed pain medications usually ease any discomfort felt at the biopsy site, and ice can be used to reduce swelling.

A doctor should be notified if the patient:

feels severe pain for more than 24 hours after the procedure experiences persistent bleeding or notices more than a few drops of blood on the wound dressing has a temperature above 101F (38.3C) inflammation and pus at the biopsy site and other signs of infection