Investigations Flashcards
1
Q
Investigation
Acromegaly
A
- Serum IGF-1;
- Oral glucose tolernce test (+ve, failure of suppression of GH after 75g of oral glucose load);
- pit function tests: 9am cortisol, free T4 and TSH, LH/FSH, testosterone, prolactin;
- MRI of brain
2
Q
Investigation
Adrenal insufficiency
A
- Dx: 9am serum cortisol (<100nmol/L and >550 makes it unlikely) or short Synacthen test (IM 250 ug tetrocosactrin - synth ACTH, serum cortisol <550nmol/L at 30 min = adrenal failure)
- ID level of defect -> High in 1ry disease, Low in 2ry and Long synacthen test (1mg synth ACTH admin, measure serum cortisol at 0, 30, 60, 90 and 120 min and then measure again at 4, 6, 8, 12 and 24hrs; pts with 1ry show no increase after 6hrs)
- ID the cause = AutoAb (against 21-OHase), abdoCT/MRI, other tests (adrenal biopsy, culture, PCR)
- Check TFTs
- In addisonian crisis = FBC, U+E (high urea, low Na, high K), CRP/ESR, Ca, glucose (low), blood cultures, urinalysis, culture and sensitivity
3
Q
Investigation
Alcohol dependence
A
- Bloods: macrocytic anaemia, high GGT, AST/ALT, others: high uric acid, triglycerides, markers of organ damage
- Acute overdose: blood alcohol, glucose, ABG, U+Es, tox screen - drug OD
4
Q
Investigation
Disseminated intravascular coagulation
A
- Bloods: FBC - low platelets/Hb/fibrinogen, high APTT/PT/fibrin degradation products/D-dimers
- Peripheral blood film: schistocytes
5
Q
Investigation
HF
A
- Bloods -> FBC, U&E, LFT, CRP, Glucose, lipids, TFT, (ALVF: ABG, BNP^ and troponin);
- CXR -> Alveolar shadowing, Kerley B lines, Cardiomegaly, upper lobe Diversion, pleural Effusion;
- ECG -> normal?, ischaemic changes or arrhythmia/LV hypertrophy;
- EchoCG -> assess ventricular contraction, sys function = LV ejection fraction <40%, diastolic = restrictive filling defect;
- swan-ganz catheter = measurement of right atrial, right ventricle, pulm artery/wedge and LV end-diastolic pressures
6
Q
Investigation
Multiple Sclerosis
A
- Dx is based on the finding of 2 or more CNS lesions with corresponding syx separated in time and space (McDonald criteria);
- LP = microscopy and CSF electrodes showing unmatched oligoclonal bands);
- MRI brain, cervical and thoracic spine, plaques can be identified and gadolinium enhancement shows active lesions;
- evoked potentials: visual, auditory and somatosensory evoked potentials may show delayed conduction velocity
7
Q
Investigation
Pancreatic cancer
A
- Bloods = CA19-9, CEA is elevated,
- obstructive jaundice = high bilirubin/ALP/deranged clotting;
- imaging = USS, CT w/out guided biopsy, MRI/MRCP, ERCP (may allow biopsy bile, cytology and stenting)
8
Q
Investigations
infective endocarditis
A
- Bloods: FBC (high neutrophils, normocytic anaemia), high ESR/CRP, U&Es - also tend to be Rheumatoid factor positive
- Urinalysis: microscopic hameaturia, proteinuria
- Blood culture: microscopy and sensitivities
- EchoCG: Transthoracic/transoesophageal
- Duke’s classification: Dx infective endocarditis based on findings of investigations and S&S
9
Q
Investigations
Glomerulonephritis
A
- Bloods = FBC, U&Es and creatinine, LFTs, lipid profile, complement studies,
- Ab = ANA, anti-dsDNA, ANCA, anti-GBM ab, cryoglobulins;
- urine = microscopy, 24hr collection (creatinine clearance and protein);
- imaging = renal tract USS to exclude other pathology;
- renal biopsy = microscopy;
- investigations for associated conditions (HBV, HCV and HIV serology)
10
Q
Investigations
1ry hyperaldosteronism
A
- Screening tests: low serum K (normal sNa), High urine K, high plasma aldosterone concentration, high aldosterone:renin activity ratio;
- confirmatory tests:
- Salt loading: failure of aldosterone suppression following salt load = 1ry
- postural test = measure plasma aldosterone, renin activity and cortisol when pt lying down at 8am, then measure again after 4hrs of pt being upright =
- aldosterone-producing adenoma = aldosterone decreases between 8am-12pm;
- bilat adrenal hyperplasia = adrenals respond to standing posture and increase renin production, increasing aldosterone production
- CT/MRI
- Bilat adrenal vein catheterisation = measuring aldosterone levels to distinguish between Conn’ sand BAH
- Radiolabelled cholesterol scanning = unilat uptake in adrenal adenomas, bilat uptake in BAH
11
Q
Investigations
AAA
A
- Bloods -> FBC, clotting screen, renal/liver function and cross match if surgery planned;
- US to detect AAA,
- CT with contrast for rupture check,
- MRI angiography
12
Q
Investigations
Achalasia
A
- CXR: widened mediastinum, double right heart border, air fluid level in upper chest, absence of normal gastric air bubble
- Barium swallow: dilated oesophagus, smooth taper down to the sphincter
- Endoscopy to exclude malignancy, mimic achalasia
- Manometry: to assess pressure at LOS = elevated resting LOS pressure, incomplete LOS relaxation, absence of peristalsis in SM portion of oesophagus
- Can do serology for Ab for chagas disease
13
Q
Investigations
Acute cholangitis
A
- Bloods: FBC high WCC, CRP/ESR ?raised, LFTs: obstructive jaundice so raised ALP and GGT;
- U+Es:sx of renal dysfunction;
- blood culture for sepsis;
- amylase raised if lower part of common bile duct involved
- Imaging: XR KUB for stones;
- Abdo USS for stones and dilation of common bile duct;
- contrast enhanced CT/MRI for dx;
- MRCP: necessary for non-calcified stones
14
Q
Investigations
Acute Kidney Injury
A
- Urinalysis = blood (nephritic), leucocyte esterase and nitrites (UTI), glucose, protein, urine osmolality;
- Bloods = FBC, blood film, U&Es, clotting, CRP, Immunology - sIg, ANA, complement, anti-GBM, antistreptolysin-O Ab, virology - hepatitis and HIV;
- US for postrenal cause and hydronephrosis;
- CXR pulm oedema,
- AXR renal stones
15
Q
Investigations
Acute lymphoblastic leukaemia
A
- Bloods: FBC is normochromic normocytic anaemia, low platelets, variable WCC, high uric acid, high LDH, clotting screen
- Blood film: abundant lymphoblasts
- Bone marrow aspirate or trephine biopsy: hypercellular with >20% lymphoblasts
- Immunophenotyping: using Ab to recognise cell surface antigens
- Cytogenic - karyotyping to look for chromosomal abnormalities or translocations
- Cytochemistry
- LP: check CNS involvement
- CXR: may show mediastinal lymphadenopathy, lytic bone lesions
- Bone radiographs: mottled appearance with punched out lesions due to leukaemic infiltration
16
Q
Investigations
Acute myeloblastic leukaemia
A
- Bloods: FBC - low Hb, low platelets, variable WCC, high uric acid, high LDH, clotting studies, fibrinogen, D-dimers
- Blood film: myeloblasts
- Bone marrow aspirate or biopsy: hypercellular with >20% blasts
- Immunophenotyping - Ab agaisnt surface Ag used to classify the lineage of the abnormal clones
- Cytogenetics
- Immunocytochemistry
17
Q
Investigations
Acute pancreatitis
A
- Blood: very high serum amylase, high WCC, U+Es, high glucose, high CRP, low Ca, LFTs, ABG
- USS: evidence of gallstones in biliary tree
- Erect CXR Pleural effusion or bowel perf
- AXR: exclude other acute abdo
- CT scan
18
Q
Investigations
AF
A
- ECG (uneven baseline, absent p waves, irreg intervals between QRS; atrial flutter = saw toothed appearance);
- Bloods (cardiac enzymes, TFT, lipid profile, U&E/Mg2+/Ca2+);
- EchoCG (mitral valve disease, left atrial dilatation, left ventricular dysfunction, structural abnormalities)
19
Q
Investigations
Alcoholic hepatitis
A
- Bloods: FBC: low Hb, high MCV, high WCC, low platelets;
- LFTS: high AST/ALT, high bilirubin, high ALP/GGT, low albumin;
- U+Es: urea and K tend to be low;
- clotting: prolong PT
- US: other liver impairment causes
- Upper GI endoscopy: investigate varices
- Liver biopsy: distinguish from other causes of hepatitis
- EEG: slow wave activity = encephalopathy
20
Q
Investigations
Amyloidosis
A
- Tissue biopsy;
- urine (check for proteinuria, free IG light chains in AL);
- Bloods: CRP/ESR, RhF, Ig levels, serum protein electrophoresis, LFTs, U+Es;
- SAP scan - radiolabelled SAP will localise the deposits of amyloid
21
Q
Investigations
Anaphylaxis
A
- Clinical dx; serum tryptase, histamine levels or urinary metabolites of histamine may help support the clinical dx
- Following an attack: allergen skin testing IDs allergen;
- IgE immunoassays, finding food specific IgE in serum
22
Q
Investigations
Ankylosing spondylitis
A
- Bloods: FBC - anaemia of chronic disease, RhF, ESR/CRP is high;
- radiographs: AP and lat radiographs of the spine (bamboo spine; symmetrical blurring of joint margins);
- later stages: Erosions, sclerosis, sacroiliac joint fusion;
- CXR: check for apical lung fibrosis
- LFTs: assess mechanical ventilatory impairment due to kyphosis
23
Q
Investigations
Anti-phospholipid syndrome
A
- FBC - low platelets;
- ESR usually normal;
- U+Es can get APL nephropathy;
- clotting screen - high APTT;
- Presence of antiPL Ab may be demonstrated by: ELISA testing for anticardiolipin ab, lupus anticoagulant assays
24
Q
Investigations
Aortic dissection
A
- Bloods: FBC, X match 10u of blood, U&E, clotting screen;
- CXR (widened mediastinum),
- ECG (normal unless LV hypertrophy/ inf MI signs),
- CT thorax
- EchoCG,
- Cardiac cath and aortography
25
Investigations
Aortic regurg
1. CXR (cardiomegaly, dilatation of asc aorta, sx of Pulm oedema),
2. ECG (LV hypertrophy: deep S in V1/2, Tall R in V5/6, inverted T in I/aVL/V5/6, L axis dev),
3. EchoCG (underlying path, monitor progression and see size),
4. Cardiac catheter with angiography
26
Investigations
aortic stenosis
1. ECG: LV hypertrophy shown (deep S in V1/2, tall R in V5/6, inverted T in 1/aVL/V5/6, L axis deviation) and LBBB
2. CXR (post-sternotic enlargement of asc aorta, calcification of aortic valve);
3. EchoCG (assesses LV function);
4. cardiac angiography (DDx from angina/MI
27
Investigations
Aplastic anaemia
1. Bloods: FBC: low Hb/platelets/WCC/absent reticulocytes, normal MCV
2. Blood film to exclude leukaemia (abnormal circ WBC)
3. Bone marrow trephine biopsy
4. Fanconi's anaemia - increased chromosomal breakage in lymphocyte cultures in presence of DNA cross linking agents
28
Investigations
Appendicitis
1. Bloods: high WCC and CRP;
2. US may help;
3. CT for dx
29
Investigations
ARDS
1. CXR: bilat alveolar infiltrates and interstitial shadowing
2. Bloods: figure out cause, FBC, U+Es, LFT, ESR/CRP, amylase, ABG, blood culture, sputum culture, plasma BNP \<100 pg/mL distinguish ARDS from HF
3. Echo: severe dysfunction of aortic/mitral valve, low left ventricular ejection fractions = haemodynamic oedema rather than ARDS
4. Pulm artery catheterisation: check pulm cap wedge pressure
5. Bronchoscopy: if cause not from hx
30
Investigations
Arterial Ulcer
1. Duplex US of lower limbs,
2. ankle-brachial pressure index,
3. percutaneous angiography,
4. ECG,
5. Fasting serum lipids/blood glucose and HbA1c,
6. FBC
31
Investigations
Aspergillus lung disease
1. Aspergilloma:
1. CXR = round mass with crescent of air around it;
2. CT/MRI if CXR unclear; sputum culture could be negative
2. ABPA:
1. immediate skin test reactivity to asp Ag, eosinophilia, raised total sIgE and specific sIgE and IgG to A. fumigatus;
2. CXR = transient patchy shadows, collapse, distended mucous filled bronchi,
3. complications = fibrosis in upper lobes and bronchiectasis;
4. CT = lung infiltrates and central bronchiectasis;
5. lung function tests = reversible airflow limitation and reduced lung volumes/gas transfer
3. Invasive aspergillosis:
1. cultures/histological exam;
2. broncheoalveolar lavage fluid/sputum may be used diagnostically;
3. Chest CT = nodules with halo sign,
32
Investigations
Aspirin OD
1. Bloods: salicylate levels, FBC,
2. U+Es check for hypoK,
3. LFTs high AST/ALT,
4. clotting screen - high PT,
5. other drug levels (paracetamol),
6. ABG - mixed met acidosis and resp alk
7. ECG: Sx of hypoK - flattened/inverted T waves, U waves, prolonged PR interval, ST depression
33
Investigations
Asthma
1. Acute: **_peak flow,_** pulse oximetry, ABG, CXR, FBC (WCC raised if infective exacerbation), CRP, U&Es, blood and sputum cultures
2. Chronic: **_peak flow monitoring_** (diurnal variation with dip in the morning), pulm function test, bloods: eosinophilia, IgE level, asp Ab titres, skin prick tests (ID allergens)
34
Investigations
Autoimmune hepatitis
1. Bloods: LFTs: high: AST/ALT/GGT/ALP/bilirubin, low: albumin (severe);
2. Clotting: high PT;
3. FBC: low Hb, platetes and WCC;
4. hypergammaglobulinaemia: presence of ANA, ASMA and anti-LKM Ab
5. Liver biopsy: needed to establish dx and check hepatitis vs cirrhosis
6. Rule out other causes of liver disease: viral serology, urinary copper/caeruloplasmin, ferritin and transferrin saturation, alpha-1 antitrypsin, anti-mitochondrial antibodies
7. US/CT/MRI of liver and abdo: visualise structural lesions
8. ERCP: rule out PSC
35
Management
Barett's oesophagus
1. Premalignant/high grade dysplasia: oesophageal resection, eradicative mucosectomy
2. Other techniques: endoscopic targeted mucosectomy, mucosal ablation by epithelial laser, radiofrequency or photodynamic ablation
3. Low-grade dysplasia: annual endoscopic surveillance is recommend
4. No pre-malingant changes found: surveillance endoscopy and biopsy performed every 1-3yrs, anti-reflux measures
36
Investigations
Behcet's disease
1. Dx very clinical;
2. pathergy test = needle prick becomes inflamed and a sterile pustule develops within 48hrs;
3. can measure complement levels and check for a positive FHx
37
Investigations
Benign breast disease
1. Triple assessment: clinical examination
2. Imaging: mammography (2-view), US in younger pts
3. Cytology/histology: fine needle aspiration - sent for cytological analysis; excision biopsy - sent for hitological analysis
38
Investigations
Biliary colic
1. Urinalysis, CXR, ECG to exclude other causes;
2. US: look for dilatation of CBD, gallbladder wall may be thickened;
3. LFT; ERCP dx and therapeutically;
4. CT: may be useful if other forms of imaging have been insufficient
39
Investigations
BPH
1. Urinalysis = for UTI and blood;
2. Bloods = U&Es for renal and PSA;
3. midstream urine (MC&S);
4. Imaging = US of urinary tract (hydronephrosis), bladder pre and post voiding, trans-rectal USS for bladder size and vol;
5. flexible cystoscopy
40
Investigations
BPPV
Hallpike tests
41
Investigations
Breast abscess
USS, MC+S of pus samples
42
Investigations
Breast Cancer
1. Triple assessment =
1. clinical assessment,
2. imaging = US (\<35) OR mammogram (\>35),
3. tissue diagnosis = fine needle aspiration OR core biopsy;
2. Sentinel LN biopsy (radioactive tracer injected into tumour, ID sentinel LN and then biopsy node for spread);
3. staging = CXR, liver US, CT (brain/thorax);
4. bloods = FBC, U&Es, Ca, bone profile, LFTs, ESR
43
Investigations
Bronchiectasis
1. Sputum for culture and sensitivity = P. aeruginosa, H influenzae, S aureus, strep pneumo, klebsiella, mycobacteria;
2. CXR = dilated bronchi, fibrosis, atelectasis, pneumonic consolidations;
3. High res CT shows bronchi dilated with thick walls;
4. bronchography;
5. sweat electrolytes for CF, serum Ig, mucociliary clearance study
44
Investigations
Burns injury
1. Bloods: O2 sat, ABG, carboxyHb (inhalation injury), FBC, U+E, Group and save
2. Serum CK, urine myoglobin (check muscle damage), ECG
45
Investigations
Candidiasis
1. Oral candidiasis - swabs and cultures not particularly useful as in many people's mouths
2. Swabs relevant for drug resistance check;
3. therapeutic trials of anti-fungal can help with dx
4. Oesophageal candidiasis definitive dx by endoscopy
5. Invasive candidiasis: blood cultures required if candidaemia is possible
46
Investigations
Carcinoid syndrome
1. 24 hr urine collection (check 5-HIAA levels),
2. bloods (plasma chromogranin A/B and fasting gut hormones), CT/MRI scan (localise tumour),
3. radioisotope scan (radiolabelled somatostatin analogue helps localise the tumour),
4. investigations for MEN-1
47
Investigations
Cardiomyopathy
1. CXR,
2. ECG (ST changes, conduction defects, arrhythmia, hypertrophic - left axis deviation, signs of LV hypertrohpy, Q waves in inferior/lat leads; restrictive - low voltage complexes),
3. EchoCG
1. dil ventricles with global hypokinesia;
2. hypertrophic = in ventricle, assymetrical septal hypertrophy;
3. restrictive = non-diil/hypertrophied ventricles, atrial enlargement, preserved sys function, diastolic dysfunction, granular/sparkling appearance of myocardium in amyloidosis
4. cardiac catheterisation,
5. endomyocardial biopsy,
6. pedigree/genetic analysis
48
Investigations
Carpal Tunnel syndrome
1. Bloods: TFTs, ESR;
2. Nerve conduction study: shows impaired median nerve conduction across the carpal tunnel
49
Investigations
Cellulitis
1. Bloods: WCC, blood culture
2. Discharge: sample and send for MC&S
3. Aspiration - if pus suspected
4. CT/MRI - orbital cellulitis is suspected (helps assess posterior spread of infection
50
Investigations
Cervical spondylosis
1. Spinal XR (lat - can detect OA change, rarely dx if non-traumatic);
2. MRI: allows assessment of root and cord compression, helps exclude spinal cord tumour and nerve root infiltration by granulomatous tissue;
3. needle EMG
51
Investigations
Cholangiocarcinoma
1. Bloods = FBC, U+Es, LFTs (high ALP and GGT),
2. clotting screen,
3. tumour markers (CA19-9 is marker of pancreatic cancer and cholangiocarcinoma);
4. endoscopy;
5. USS, CT, MRI,
6. Bone scan for staging
52
Investigations
Cholecystitis
1. Bloods: FBC - high WCC in cholecystites and cholangitis;
2. LFT high ALP/GGT;
3. blood cultures;
4. amylase
5. US: show gallstones, increased thickness of gallbladder wall, dilatation of biliary tree
6. AXR: but only 10% of gallstones are radioopaque
7. Other imaging - to exclude differentials
53
Investigations
Chronic Kidney disease
1. Assess renal function = urea (not good, varies with diet/hydration), creatinine (useful but limitations), isotopic GFR (expensive but gold standard);
2. biochem = glucose, K (raised), check Na, HCO3, Ca, PO4;
3. serology = Ab (ANA, c-ANCA, anti-GBM), hepatitis, HIV;
4. Urinalysis = check for proteinuria/haematuria, check for 24hr urine collection, serum/urine protein electrophoresis;
5. imaging = USS, CT/MRI, XR KUB; renal biopsy
54
Investigations
Chronic lymphocytic leukaemia
1. May be associated with AI, such as haemolytic anaemia or thrombocytopaenia
2. Bloods: FBC; lymphocytosis, low Hb (bone marrow infiltration, hypersplenism, autoimmune haemolysis), low platelets, low serum Ig
3. Blood film: small lymphocytes with thin rims of cytoplasm, smudge cells
4. Bone marrow aspirate or biopsy - lymphocytic replacement of normal marrow
5. cytogenetics
55
Investigations
Chronic myeloid leukaemia
1. Bloods: FBC: high WCC, low Hb, high basophils/neutrophils/eosinophils;
2. high/normal/low platelets, high uric acid, high B12 and transcobalamin
3. Blood film: immature granulocytes
4. Bone marrow aspirate or biopsy: hypercellular with raised myeloid-erythroid ratio
5. Cytogenetics: show the philadelphia chromosome
56
Investigations
Chronic pancreatitis
1. Bloods: high glucose (OGTT), amylase/lipase normal, high Ig
2. US
3. ERCP/MRCP: early changes = main duct dilatation and stumping of branches;
4. late changes = duct strictures with alternating dilatation
5. Abdo XR: calcification of pancreas
6. CT scan: same as AXR
7. Test of pancreatic exocrine function: faecal elastase - pacreatic exocrine function
57
Investigations
Cirrhosis
1. Bloods: FBC: low pts+Hb, LFTs: normal but often high AST/ALT/ALP/GGT/bilirubin, low albumin;
2. clotting: prolonged PT;
3. serum AFP: raised chronic liver disease, high levels suggest hepatocellular carcinoma
4. To determine cause: viral serology, A1anti-trypsin, caeruloplasmin, iron studies for haemochromatosis, anti-mitochondrial Ab, ANA/ASMA
5. Ascitic tap: MC+S, biochem, cytology, ascitic tap w/neutrophils \>250/mm3 = spontaneous bacterial peritonitis
6. Liver biopsy: performed percutaneously, transjugular;
7. histopathological features of cirrhosis: periportal fibrosis, loss of normal liver architecture, nodular appearance;
8. Grade: indicates degree of inflammation;
9. Stage: degree of architectural distortion
10. Imaging: US, CT, MRI for ascites, HCC, hepatic/portal vein thrombosis, exclude biliary obstruction; MRCP
11. Endoscopy - varices
12. Child pugh grading: score for estimating prognosis in chronic liver disease/cirrhosis: albumin, bilirubin, PT, ascites encephalopathy;
13. cirrhosis divided into classes using: Class A: 5-6, Class B: 7-9, Class C: 10-15
58
Investigations
Coeliac disease
1. Blood: FBC (low Hb, iron, folate), U+Es, albumin, calcium, Phosphate
2. Serology: IgG anti-gladin Ab, IgA and IgG anti-endomysial tranglutaminase Ab can be dx;
1. IgA def quite common
3. Stool: culture to exclude infection, faecal fat tests for steatorrhoea
4. D-xylose test: reduced urinary excretion after oral xylose indicates small bowel malabsorption
5. Endoscopy: direct visualisation of vilous atrophy in the small intestine, villous atrophy and crypt hyperplasia in duodenum
59
Investigations
Colorectal cancer
1. Bloods = FBC (anaemia), LFTs, tumour markers (CEA);
2. Stools FOBT as screening test;
3. endoscopy can be used to biopsy tumour;
4. double contrast barium enema (apple core strictures),
5. contrast CT for Duke's staging
60
Investigations
Constrictive pericarditis
1. CXR (calcification on pericardium),
2. echoCG,
3. MRI (thickness of pericardium),
4. CT, pericardial biopsy (ifi infective cause)
61
Investigations
COPD
1. Spirometry and pulm function tests (reduced PEFR/FEV1/FVC, increased lung volumes and decreased CO gas transfer coefficient);
2. CXR = normal, hyperinflation, reduced peripheral lung markings, elongated cardiac silhouette;
3. bloods = FBC = increased Hb and Hct due to 2ry polycythaemia;
4. ABG;
5. ECG and echo;
6. sputum and blood cultures (in acute infective exacerbations);
7. alpha 1 antitrypsin levels
62
Investigations
Crohn's disease
1. Blood: FBC - low Hb, high platelets, high WCC; U+Es, LFTs - low albumin; high ESR, CRP may be high or normal
2. Stool microscopy and culture: exclude infective colitis
3. AXR to show toxic megacolon; erect CXR if there is a risk of perf
4. Small bowel barium follow through - fibrosis/strictures, deep ulceration, cobblestone mucosa
5. Endoscopy and biopsy: for UC vs CD;
1. useful for monitoring malignancy and disease progression;
2. show mucosal oedema and ulceration with rose thorn fissures;
3. fistulae and abscesses;
4. transmural chronic inflammation of macrophages, lymphocytes and plasma cells;
5. granulomas with epitheliod giant cells may be seen in blood vessels and lymphatics
6. Radionuclide labelled neutrophil scan: can localise the inflammation
63
Investigations
Cushing's syndrome
1. Must be performed on pts with high pretest probability;
2. bloods (U+Es hypoK due to mineralocorticoid effect, BM high glucose)
3. Initial high sensitivity tests = urinary free cortisol, late night salivary cortisol, overnight/low dose dexamethasone suppression test (give 0.5mg DXM orally every 6hrs for 48hrs; failure to suppress below 50 nmol/L)
4. Test to determine underlying cause:
5. ACTH independent -\> low plasma ACTH, CT/MRI of adrenals
6. ACTH dependent -\> high plasma ACTH, pit MRI, high-dose DXM suppression test, inferior petrosal sinus sampling (superior to HDDST)
7. ACTH dependent ectopic -\> lung cancer = CXR, sputum cytology, bronchoscopy, CT scan; radiolabelled octreotide scans can detect carcinoid tumours because they express somatostatin receotirs
64
Investigations
Depressive disorder
1. Consider organic causes - hypothyroidism, hypercalcaemia, addisons disease, cushing's disease
2. Inv for other causes: blood glucose, U+Es, TFT, Cal, FBC, MRI/CT
65
Investigations
Diabetes insipidus
1. Bloods: U+Es, Ca, increased plasma osm, decreased urine osm
2. Water deprivation test = restricted for 8hrs;
1. plasma and urine osm measured every hour for 8hrs;
2. weigh the pt hourly to monitor level of dehydration;
3. STOP the test body weight fall \>3%.
4. Desmopressin given after 8hrs and urine osm measured
3. Results = normal (water restriction causes): increased plasma osm, ADH secretion, water reabsorption, urine osm (\>600mosmol/kg);
4. DI: Lack of ADH so urine osm LOW (\<400), cranial means urine osm rises \>50% after Desmopressin, nephrogenic means urine osm rises \<45% after desmo
66
Investigations
Diverticular disease
1. Bloods: FBC increased WCC and CRP, check clotting and cross-match if bleeding
2. Barium enema: shows presence of diverticulae (saw tooth appearance of lumen);
3. reflects psuedohypertrophy of circular muscle
4. Flexible sigmoidoscopy and colonoscopy: diverticulae can be visualised and other pathology can be excluded
5. ACUTE: CT scan for evidence of disease and complications may be performed
67
Investigations
DMT1
1. Blood glucose - fasting \>7 or random bgl \>11;
2. HBA1c;
3. FBC: MCV reticulocytes; U+Es monitor for nephropathy and hyperkalaemia; lipid profile;
1. urine albumin creatinine ratio to detect microalbuminuria;
2. urine - glycosuria, ketonuria, MSU;
4. Investigations for DKA: FBC (raised WCC w/out infection), U+Es (raised urea/creatinine ), LFT, CRP, glucose, amylase, blood cultures, ABG (met acidosis with high anion gap), blood/urinary ketones
68
Investigations
DVT
Doppler US,
impedance plethysmography,
bloods (d-dimer as -ve predictor and thrombophilia screen if indicated, if PE = ECG, CXR, ABG)
69
Investigations
Eczema
1. Contact eczema: skin patch testing - disc containing allergens is diluted and applied on skin for 48hrs - if red raised lesion = positive
2. Atopic eczema: lab testing - IgE level
70
Investigations
Encephalitis
1. Bloods -\> FBC, U+Es, glucose, viral serology, ABG;
2. MRI/CT -\> exclude mass lesion, HSV causes oedema of temporal lobe on MRI;
3. Lumbar puncture -\> high lymphocytes/monocytes/protein, glucose normal, viral PCR;
4. EEG -\> epileptiform activity;
5. brain biopsy rarely needed
71
Investigations
Epididymitis and orchitis
1. Urine = dipstick, early morning urine collections for MC&S;
2. Bloods = FBC for WCC, high CRP,
3. U&Es; imaging = increased blood flow on duplex examination
72
Investigations
Epilepsy
1. Bloods -\> FBC, U+Es, LFT, glucose, Ca, Mg, ABG, toxicology screen, prolactin;
2. EEG -\> helps to confirm dx, helps classify epilepsy;
3. CT/MRI -\> structural, space occupying or vascular lesions;
4. other due to 2ry causes
73
Investigations
Erythema multiforme
1. Usually unnecessary - erythema multiforme - clinical dx; Bloods: high WC, eosinophils, ESR/CRP
2. Imaging: exclude sarcoidosis and atypical pneumonia
3. Skin biopsy: histology and direct immunoflourescence if in doubt
74
Investigations
Erythema nodosum
1. Determine cause;
2. bloods: anti-streptolysin O titres, FBC/CRP/ESR, U+Es, serum ACE (^ in sarcoidosis)
3. Throat swab and cultures
4. Mantoux/head skin testing for TB
5. CXR for bilat hilar lymphadenopathy/TB/sarcidosis/fungal infections sx
75
Investigations
Extradural haemorrhage
1. Urgent CT scan: check for haematoma, look for features of raised ICP - midline shift
76
Investigations
extrinsic allergic alveolitis
1. Bloods = FBC (neutrophilia, lymphopoenia), ABG reduced PO2/CO2;
2. serology = IgG to fungal/avian Ag;
3. CXR = normal in acute episodes, fibrosis seen in chronic cases;
4. high res CT-thorax;
5. pulm function tests = restrictive defect (low FEV1, low FVC, preserved/increased FEV1/FVC, reduced total lung capacity);
6. bronchoalveolar lavage = increased cellularity, lung biopsy can be performed
77
Investigations
Fibromyalgia
1. Clinical dx;
2. key features: Widespread pain involving both sides of the body above and below the waist for at least 3m;
3. presence of 11 tender points among 9 pairs of specific sites
78
Investigations
Gastric cancer
1. Upper GI endoscopy;
2. bloods = FBC (anaemia), LFTs;
3. CT/MRI for staging,
4. endoscopic USS - assess depth of gastric invasion and LN involvment
79
Investigations
Gastroenteritis
1. Bloods: FBC, blood culture, U+Es
2. Stool: faecal microscopy, analysis for toxins, pseudomembranous colitis
3. AXR/US: exclude other causes of abdo pain
4. Sigmoidoscopy: usually unnecessary unless IBD excluded
80
Investigations
Gastrointestinal perforation
1. Bloods: FBC, U+Es, LFTs, amylase - raised with perf
2. Erect CXR for air under diaphragm
3. AXR: shows abnormal gas shadowing
4. Gastrograffin swallow: for suspected oesophageal perf
81
Investigations
Giant cell arteritis
1. Bloods: high ESR, FBC = normocytic anaemia of chronic disease;
2. Temporal artery biopsy: must be performed within 48hrs of starting corticosteroids, negative biopsy doesn't necessarily rule out GCA
81
Investigations
Glaucoma
1. Goldmann applanation tonometry: standard method of measuring IOP, normal = 15mmHg
2. Pachymetry: using US or optical scanning to measure central corneal thickness;
3. CCT \< 590mm = higher risk of glaucoma
4. Fundoscopy: detects pathologically cupped optic disc
5. Gonioscopy: assess iridocorneal angle
6. Perimetry (visual field testing)
82
Investigations
Gout
1. Synovial fluid aspirate: monosodium urate crystals seen = needle shaped, negative birefringence under polarised light microscopy, microscopy and culture also used to exclude septic arthritis
2. Bloods: FBC riased WCC; U+Es, raised urate, raised ESR
3. AXR/KUB film -\> uric acid renal stones may be seen
82
Investigations
GORD
1. Clinical dx
2. Upper GI endoscopy, biopsy, cytological brushings to exclude malignancy
3. Barium swallow - detects hiatus hernia (repair op = Nissen fundoplication), peptic stricture, extrinsic compression of oesophagus
4. CXR: not specific for GORD but can lead to finding hiatus hernia = gastric bubble behind the cardiac shadow
5. 24hr oesophageal pH monitoring: pH probe places in lower oesophagus determining relationship between syx and oesophageal pH
83
Investigations
Graves disease
1. TFTs - low TSH and high T3/T4;
2. autoantibodies - anti-TPO antibodies (75%), anti-thyroglobulin antibodies, TSH-receptor ab (very sensitive/specific for graves);
3. imaging - thyroid US, thyroid uptake scan;
4. inflammatory markers - CRP/ESR raised in subacute thyroiditis
84
Investigations
Guillain Barre Syndrome
1. Lumbar puncture = high protein, normal cell count and glucose;
2. nerve conduction study = reduced velocity;
3. bloods = anti-ganglioside Ab in miller-fisher variant +25% of other cases;
4. spirometry = reduced FVC;
5. ECG = arrhythmias may develop
85
Investigations
Haemochromatosis
1. Haematinics: serum ferritin (high), transferrin (low), transferrin sat (high), TIBC (low);
2. other tests to exclude: CRP (inflammation), chronic alcohol consumption, ALT (liver necrosis);
3. LFTs;
4. other investigations for abnormal liver fucntion, genetic testing, liver biopsy (RARE)
86
Investigations
Haemolytic anaemia
1. Bloods: FBC = low Hb and haptoglobin, high reticulocytes/MCV/unconjugated bilirubin;
2. U+Es, folate
3. Blood film: leucoerythroblastic picture, macrocytosis, nucleated RBC/reticulocytes, polychromasia, may ID specific abnormal cells like: spherocytes, elliptocytes, sickle cells, schistocytes, malarial parasites
4. Urine: high urobilinogen, haemoglobinuria, haemosiderinuria
5. Direct coombs' test: tests for AI haemolytic anaemia, Id RBC coated with Ab
6. Osmotic fragility test or spectrin mutation analysis - Id membrane abnormalities
7. Ham's test - lysis of RBC in acidified serum in paroxysmal nocturnal haemoglobinuria
8. Hb electrophoresis or enzyme assays to exclude other causes
9. Bone marrow biopsy
87
Investigations
Haemophilia
1. Clotting screen (high APTT), coagulation factor assays (low factor 8/9/11), other investigations may be performed if there are complications (arthroscopy)
88
Investigations
Haemorrhoids
1. DRE,
2. proctoscopy,
3. rigid or flexible sigmoidoscopy: important to exclude rectal/sigmoid bleeding
89
Investigations
heart block
1. ECG
1. 1st = fixed prolonged PR interval
2. Mobitz I = progressively prolonged PR interval, culminating in P wave not followed by QRS
3. Mobitz II = intermittent P wave not followed by QRS
4. 3rd = no relation between P and QRS, if QRS initiated in bundle of hig then narrow complex, distally has wide complex
2. CXR: cardiac enlargement, pulm oedema
3. Bloods: TFT, digoxin level, cardiac enzymes, troponin
4. EchoCG: wall motion abnormalities, aortic valve disease and vegetations
90
Investigations
Hepatocellular carcinoma
1. Bloods = FBC, ESR, LFTs, Clotting, alpha-fetoprotein (tumour marker), hepatitis serology;
2. imaging = abdo USS, CT/MRI gold standard for staging;
3. histology/cytology = ascitic tap sent for cyto analysis;
4. staging = CT scan
91
Investigations
Hiatus hernia
1. Bloods: FBC for IDA;
2. Radiology: CSR with gastric air bubble seen above diaphragm, barium swallow;
3. endoscopy
92
Investigations
Hodgkin's lymphoma
1. Bloods: High ESR/CRP, FBC: anaemia of chronic disease, leucocytosis, high neutrophils, high eosinophils, lymphopaenia in advanced disease
2. LN biopsy
3. BM aspirate and trephine biopsy
4. Imaging - CXR, CT, PET
5. Ann Arbor staging:
1. I=single LN region
2. II= 2+ LN regions on one side of diaphragm
3. III= LN regions on both sides of the diaphragm
4. IV =extranodal involvement
5. A = absence of B syx
6. B= presence of B syx
7. E= localised extranodal extension
8. S = involvement of spleen
92
Investigations
HIV
1. HIV testing: HIV ab, PCR for viral RNA, CD4 count, viral load
2. Others: pneumocystic pneumonia (CXR), cryptococcal meningitis (brain CT/MRI or LP), CMV colitis (colonoscopy and biopsy), toxoplasmosis (brain CT or MRI), cryptosporidia (stool microscopy)
93
Investigations
HTN
1. Bloods (U&E, glucose, lipids),
2. urine dipstick (blood and proteins),
3. ECG (LV hypertrophy/ischaemia),
4. **_ambulatory BP monitoring_**
94
Investigations
HUS and TTP
1. FBC: normocytic anaemia, high neutrophils, very low platelets
2. U+Es: high urea, creatinine, K+; low Na
3. Clotting: normal APTT and fibrinogen levels
4. LFTs: high unconjugated bilirubin, high LDH from haemolysis
5. Blood cultures
6. ABG: low pH, HCO3, PaCO2; normal anion gap
7. Blood film: schistocytes, high reticulocytes and spherocytes
8. Urine: 1+ g protein/24hrs; haematuria
9. Stool samples: MC+S
10. Renal biopsy: can distinguish between D+ and D- HUS
95
Investigations
Hydrocephalus
1. CT head;
2. CSF (ventricular drain/LP, may indicate pathology, check MC+S, protein and glucose);
3. LP (contraindicated if raised ICP) and therapeutic in normal pressure
96
Investigations
Hydrocoele
1. US exclude tumour;
2. urine - dipstick and msu for infection;
3. blood - markers of testicular tumour = alpha-fetoprotein, beta-HCG, lactate dehydrogenase
97
Investigations
Hyperparathyroidism
1. U+Es, serum Ca (high in 1ry/3ry, low in 2ry), serum PO4, albumin, ALP, vit D, PTH, renal USS for renal calculi;
2. primary hyperparathyroidism: hyperchloraemic acidosis, normal anion gap, due to PTH inhibition of renal reabsorption of bicarbonate,
3. urine - high PTH in the presence of high Ca can also be caused by familial hypocalciuric hypercalcaemia
4. (calcium:creatinine ratio can help differentiate between 1ry and FHH)
98
Investigations
Hypogonadism - male
1. serum total testosterone, sex hormone binding globulin, albumin, LH/FSH;
2. 1ry: low testosterone, high LH and FSH, can be investigated using karyotyping
3. 2ry low testosterone, inappropriately normal/low LH/FSH; pit function tests, MRI of the hypothalamic/pit area, visual field testing, smell testing, iron testing
4. Assess bone age (risk of fx)
99
Investigations
Hypogonadism female
1. Low serum oestradiol, serum FSH/LH (1ry = high, 2ry = low)
2. 1ry: karyotype, pelvic imaging (US/MRI)
3. Screen for FMR1 gene in pts with unexplained premature ovarian failure
4. 2ry: pit function tests, visual field testing, hypothalamic-pit MRI, smell tests for anosmia, serum transferrin saturation
5. Associated conditions: Turner's syndrome: periodic echo, renal US; AI oophoritis: check autoimmune adrenal insufficiency
100
Investigations
Hypopituitarism
1. Pit function tests:
2. Basal tests: 9am cortisol, LH and FSH levels, testosterone levels, oestrogen levels, IGF-1 levels, prolactin levels, free T4/TSH levels
3. Dynamic tests: RARE, insulin induced hypoglycaemic
4. short synacthen test
5. MRI/CT brain
6. Visual field testing
101
Investigations
Hypothyroidism
Bloods: TFTs, FBC (normocytic anaemia), U+Es (low Na), cholesterol (high)
102
Investigations
IBS
1. Dx mainly from hx but organic pathology must be excludeed;
2. blood: FBC (anaemia), LFT, ESR, CRP, TFT, anti-endomysial/anti-tranglutaminase Ab
3. Stool exam: microscopy and culture for infective cause
4. US: exclude gallstone disease
5. Urease breath test: exclude dyspepsia due to h pylori
6. Endoscopy: if other pathologies suspected
103
Investigations
IHD
1. Bloods:
1. FBC
2. U&E
3. CRP
4. Glucose
5. Lipid profile
6. Cardiac enzymes (troponins, CK-MB)
7. Amylase
8. TFT
9. AST/LDH (raised 24-48h post-MI respectively)
2. ECG: Unstable angina/NSTEMI (ST depression/T wave inversion), STEMI (hyperacute T waves, ST elevation (\>1mm limb, \>2mm chest), new onset LBBB, T wave inversion and pathological Q waves); Tall R wave and ST depression in V1-3
3. CXR -\> sx of HF
4. Exercise ECG
5. Radionuclide myocardial perfusion imaging
6. EchoCG - LV Ejection fraction
7. Pharmacological stress testing: dipyrimadole, adenosine, dobutamine with Echo/rMPI to detect ischaemic myocardium
8. Cardiac catheterisation/angiography
9. Coronary calcium scoring (CT scan)
103
Investigations
Idiopathic pulmonary fibrosis
1. Bloods = ABG PCO2 rises in late stages of disease, ANA and RhF (1/3 positive);
2. CXR = normal, ground glass shadowing, later stage reticulonodular shadowing, signs of cor pulmonale and honeycombing; high res CT;
3. pulm function tests = restrictive features, decreased lung vols/compliance/lung capacity;
4. bronchoalveolar lavage;
5. lung biopsy - gold standard for dx;
6. echo
104
Investigations
Immune thrombocytopaenic purpura
1. Dx of exclusion: myelodysplasia, acute leukaemia, marrow infiltration;
2. Bloods: FBC has low platelets;
1. clotting screen: normal PT, APTT and fibrinogen; autoAb
3. Blood film: to rule out pseudothrombocytopaenia
4. Bone marrow: exclude other pathology
105
Investigations
Infectious colitis
1. Dx largely clinical,
2. stool culture may be used to identify the causative organism
105
Investigations
Infectious mononucleosis
1. Bloods: FBC leucocytosis, LFTs: high ALT/AST
2. Blood film: lymphocytosis with atypical lymphocytes
3. Heterophil Ab test (monospot test/aul bunnell test) - based on EBV ag being similar to Ag on RBC of animals but NOT humans;
1. mixing blood of EBV+ human with animal blood, makes animal RBC aggregate and precipitate out of solution -\> may give false negatives in early stages of infection before Ab generated
4. Throat swab: exclude strep tonsilitis
5. IgM/IgG to EBV viral capsid Ag
6. IgG against EB nuclear Ag
106
Investigations
Infective arthritis
1. Joint aspiration (IMPORTANT): infective arthritis, spirate will be grossly purulent, send synovial fluid for MC+S (microscopy), PCR used if viral casue is suspected
2. Bloods:
1. FBC high WCC, high neutrophils;
2. high CRP and ESR;
3. blood cultures - MC+S;
4. viral serology may be useful
3. Plain joint radiographs: affected joint may look normal initially, show sx of damage following the infection
4. MRI scan: useful for detecting osteomyelitis
107
Investigations
Inguinal hernias
1. If acute with painful, irreducible hernia;
2. Bloods: FBC, U+E, CRP, clotting, group and save for ops, ABG - lactic acidosis from bowel ischaemia
3. Imagining: erect CXR - check for perf;
4. USS - exclude other causes of groin lump;
5. AXR - check for obstruction
108
Investigations
Intestinal obstruction
1. AXR - for dx and localisation,
2. check for valvulae conniventes or haustra;
3. water soluble contrast enema,
4. barium follow through
108
Investigations
Intestinal ischaemia
1. Dx based on clinical suspicion/after laparotomy;
2. AXR - thickening of small bowel folds and sx of obstruction;
3. bloods: ABG (lactic acidosis), FBC, U+Es, LFTs, Clotting, cross-match;
4. mesenteric angiography: only if stable
109
Investigations
Liver abscesses and cysts
1. Bloods: FBC: mild anaemia, leukocytosis, high eosinophils; LFTs: high ALP, high bilirubin;
2. high ESR/CRP, blood cultures, amoebic and hydatid serology
3. Stool MC+S for e hystiolytica
4. Liver US or CT/MRI localises structure of mass
5. CXR: for right PE or atelactasis, raised hemidiaphragm
6. Aspiration and culture of abscess material - most pyogenic liver abscesses are polymicrobial, amoebic abscesses have fluid of necrotic hepatocytes and trophozoites
110
Investigations
Liver failure
1. ID the cause: viral serology, paracetamol levels, autoAb (ASM, anti-LKM), ferritin (haemochromatosis), caeruloplasmin and urinary copper (wilson's disease)
2. bloods: FBC low Hb (GI bleed)/high wcc (infection); U+Es (renal failure); glucose; LFTs: high bilirubin, high AST/ALT/ALP/GGT, low albumin, ESR/CRP, coagulation screen, ABG to determine blood pH, group and save
3. Liver US/CT
4. Ascitic Tap: send for MC+S, neutrophils \>250/mm3 = spontaneous bacterial peritonitis
5. Doppler scan of hepatic or portal veins - Budd-chiari syndrome
6. EEG - monitor encephalopathy
111
Investigations
Lumbosacral radiculopathy - sciatica
1. Clinical dx;
2. straight leg raise: pain in distribution of the sciatic nerve is reproduced on passive flexion of the straight leg at hip between 30-70 degrees, then it is considered a positive sign (Lasegue's sign), test is sensitive but not specific;
3. CT/MRI: helps visualise lumbar disc herniation
112
Investigations
Lung cancer
1. Dx = CXR, sputum cytology, bronchoscopy with brushings/biospy, CT/US-guided percutaneous biopsy, LN biopsy;
2. Staging = CT/MRI of head, chest and abdomen;
3. Bloods = FBC, U&Es, Ca (hyper is common), ALP (raised with bone mets), LFTs;
4. Pre-op = ABG, pulm function tests
113
Investigations
Macrocytic anaemia
1. Bloods: FBC: high MCV,
1. pancytopaenia in megaloblastic anaemia, exclude reticulocytes;
2. LFTs (high billirubin), ESR, TFT, serum vit b12, red cell folate, anti-parietal cell and anti-intrinsic factor Ab,
3. serum protein electrophoresis for dense band in myeloma
2. Blood film: large erythrocytes;
1. megaloblastic: megaloblasts and hypersegmented neutrophil
3. Schilling test: for pernicious anaemia, B12 only absorbed when given IF
4. Bone marrow biopsy
5. Investigations for cause
114
Investigations
Malaria
1. Thin/thick blood films: thick for quantifying and thin for ID type of malaria
2. Bloods:FBC (haemolytic), U+E. LFTs, ABG
3. Urinalysis to check for blood/protein
4. Thin/thick blood films: thick for quantifying and thin for ID type of malaria
5. Bloods:FBC (haemolytic), U+E. LFTs, ABG
6. Urinalysis to check for blood/protein
115
Investigations
Mallory weiss tear
1. OGD,
2. bloods: FBC to check for anaemia
116
Investigations
Melanoma
1. Excisional biopsy: histological dx and determination of Clark's levels and breslow's thickness
2. Lymphoscintigraphy - radioactive compound is injected into the lesion and images are taken over 30 min to trace the lymphatic drainage and ID sentinel nodes
3. Sentinel Lymph node biopsy - for metastatic involvement
4. Staging using USS, CT/MRI, CXR
5. Bloods: LFTs (liver common site of mets)
117
Investigations
MEN
1. MEN1:
1. screening 1st/2nd degree relatives;
2. hormone hypersecretion blood tests,
3. DNA testing
2. MEN2:
1. phaeo test (24hr urine metanephrines, followed by abdo MRI),
2. medullary thyroid cancer test (elevated calcitonin conc; also investigated with US and FNA);
3. Parathyroid tumours (simultaneously elevated Ca and PTH
118
Investigations
Meningitis
1. Bloods (2 blood cultures),
2. imaging (CT scan, exclude raised ICP before LP),
3. LP (MC+S, bacterial = cloudy CSF, high neutrophils/protein, low glucose;
4. TB meningitis = fibrinous CSF, high lymphocytes/protein, low glucose)
119
Investigations
Mesotheliomas
1. CXR/CT (show pleural effusion, maybe = pleural mass and rib destruction),
2. MRI,
3. PET,
4. Pleural fluid sent for cytological analysis and may be blood stained,
5. pleural biopsy
120
Investigations
Microcytic anaemia
1. Bloods: FBC (low Hb, low MCV, reticulocytes), serum irone, total iron binding capacity is high in iron def, serum ferritin (low), serum lead
2. Blood film:
1. IDA: microcytic, hypochromic, anisocytosis, poikilocytosis
2. Sideroblastic anaemia: dimorphic blood film, hypochromic microcytic cells
3. Lead poisoning: basophilic stippling
3. Hb electrophoresis: for thalassaemia
4. Sideroblastic anaemia: ring sideroblasts in bone marrow
5. Special inv if IDA \>40, male and/or post menopausal women: upper GI endoscopy, colonoscopy, haematuria
121
Investigations
mitral regurg
1. ECG: normal/AF. p mitrale (left atrial hypertrophy);
2. CXR: acute MR shows LV failure, chronic MR shows LA enlargement, cardiomegaly and mitral valve calcification;
3. EchoCG: every 6-12months in mod-severe MR, assessment of LV EF and end-systolic dimension
122
Investigations
Mitral stenosis
1. ECG: normal, p mitrale (broad p wave with bunny ears), AF, RV hypertrophy evidence if severe pulm HTN;
2. CXR: LA enlargement, cardiac enlargement, pulm congestion, mitral valve calcification;
3. echoCG: assess functional and structural impairments, transoesophageal echoCG;
4. Cardiac catheterisation: severity of HF
123
Investigations
Motor Neurone Disease
1. Bloods = mild elevation in CK, ESR, anti-GM1 ganglioside antibodies;
2. EMG;
3. Nerve conduction studies (normal),
4. MRI (exclude cord compression and brainstem lesiions),
5. spirometry (assess respiratory muscle weakness)
124
Investigations
Multiorgan dysfunction syndrome
1. Monitor vital sx, ABG necessary to look at hypoxaemia, lactic acidosis
125
Investigations
Multiple myeloma
1. Bloods: High ESR/?CRP; U+E - high creatinine, high Ca; normal ALP; FBC - low Hb, normochromic, normocytic
2. Blood film: rouleaux formation with high protein
3. Serum/urine electrophoresis - serum paraprotein, Bence-Jones protein
4. Bone marrow aspirate and trephine - high plasma cells
5. Chest, pelvic or vertebral XR - osteolytic lesions with surrounding sclerosis, pathological fractures
126
Investigations
Myasthenia gravis
1. Bloods: CK, serum ACh receptor Ab, TFTs, anti-voltage gated Ca channel ab (LES)
2. Tensilon test: short acting anti-cholinesterase increases Ach levels and causes a rapid and transient improvement in clinical features, risk of bradycardia (generally avoided)
3. Nerve conduction study: repetitive stimulation shows decrements of muscle action potential
4. EMG
5. CT thorax/CXR - visualise thymoma in the mediastinum or lung malignancies
127
Investigations
Myelodysplasia
1. Bloods - FBC in pancytopaenia
2. Blood film: normo/macrocytic red cells; variable microcytic red cell in RARS, low granulocytes, granulocytes are not granulated, high monocytes in CMML
3. Bone marrow aspire or biopsy: hypercellularity, ringed sideroblasts (haemosiderin deposits in the mitochondria of erythroid precursors forming an apparent ring around the nucleus; abnormal granulocyte precursors, 10% show marrow fibrosis
128
Investigations
Myelofibrosis
1. Bloods: FBC: initially variable Hb, WCC and platelets; later stages -\> anaemia, leukopaenia, thrombocytopaenia; LFTs are abnormal
2. Blood film: leucoerythroblastic changes, tear drop poikilocyte red cells
3. Bone marrow aspirate or biopsy: Aspiration usually unsuccessful - dry tap, trephrine biopsy shows fibrotic hypercellular marrow with dense reticulin fibres on silver staining
129
Investigations
Myocarditis
1. Bloods: FBC (^WCC if infective), U&E, ESP/CRP raised, cardiac enzyme may be raised, tests to ID cause (serology);
2. ECG: non specific T wave and ST changes, saddle shaped ST elevation with pericarditis;
3. CXR: normal/cardiomegaly;
4. pericardial fluid drainage: glucose, protein, cytology, culture and sensitivity;
5. EchoCG: assess sys and dias function, wall motion abnormalities, pericardial effusions;
6. myocardial biopsy is rarely required
130
Investigations
Nephrotic syndrome
1. Bloods = FBC, U&Es, LFTs, ESR/CRP, glucose, lipid profile, Ig, complement;
2. ID cause = SLE (ANA, anti-dsDNA ab), Infections (group A beta-haemolytic strep infection (ASO titre), HBV infection (serology), plasmodium malariae (blood film)), goodpasture's syndrome (anti-glomerular basement ab), vasculitides (polyangitis with granulomatosis, microscopic polyarteritis);
3. urine = urinalysis, MC&S, 24hr collection (calculate creatinine clearance and 24hr protein excretion);
4. renal US = exclude other cause; renal biopsy;
5. other imaging = doppler US, renal angiogram, CT/MRI
131
Investigations
Neurofibromatosis
1. Ophthalmological assessment,
2. audiometry,
3. MRI brain and spinal cord (for vestibular schwannomas, meningiomas and nerve root fibromas),
4. skull XR (sphenoid dysplasia in NF1),
5. genetic testing
132
Investigations
Neutropenic sepsis
1. FBC (neutrophil level),
2. Blood cultures (sepsis),
3. others = blood film, D-dimer, U&Es, creatinine, LFTs
133
Investigations
Non-alcoholic steatohepatitis
1. LFTs: elevated AST and ALT;
2. liver US steatosis,
3. liver biopsy
134
Investigations
Non-functioning pituitary tumours
1. MRI,
2. CT,
3. bloods for hormone levels,
4. visual field testing
135
Investigations
Non-hodgkin's lymphoma
1. Bloods: FBC - anaemia, neutropaenia, thrombocytopaenia; high ESR/CRP, Ca may be raised, HIV/HBV/HCV serology
2. Blood film - lymphoma cells may be visible in some pts
3. Bone marrow aspiration and biopsy
4. Imaging - CXR, CT, PET
5. LN biopsy - allows histopathological evaluation, immunophenotyping and cytogenetics
6. Staging: Ann-Arbor
136
Investigations
Normocytic anaemia
FBC - check Hb and MCV; check hx for haemorrhage
137
Investigations
Obesity
1. Measure serum lipids,
2. measure HbA1c,
3. hormone profile (check hormonal cause),
4. TFTs,
5. other investigations
138
Investigations
Obstructive sleep apnoea
1. Sleep study = monitor airflow, resp effort, pulse oximetry and HR;
2. bloods = TFTs, ABG
139
Investigations
Oesophageal cancer
1. Endoscopy (brushings and biopsy),
2. imaging (barium swallow and CXR),
3. staging (CT chest and abdo),
4. other (bronchoscopy, Lung FT, ABGs)
140
Investigations
Opiates OD
1. Toxicology screen,
2. paracetamol blood level,
3. small test dose of naloxone if in doubt,
4. ABG, FBC
141
Investigations
Osteoarthritis
1. Joint XR of affected joint will show 4 classic features -\>
1. narrowing of joint space,
2. osteophytes,
3. subchondral cysts,
4. subchondral sclerosis
142
Investigations
Osteomyelitis
1. Bloods: fbc, culture, esr, crp;
2. swabs of wound/discharge;
3. radioisographs;
4. radioisotope bone scan, shows area of increased activity
143
Investigations
Osteoporosis
1. Bloods: Ca, PO4, ALP (NORMAL in 1ry);
2. XR: to dx fx, often normal, can show biconcave vertebrae and crush fx;
3. Isotope bone scan to highlight areas of stress and microfx;
4. DEXA: T-score (no. of sd the BMD is above or below theyoung normal mean BMD) or Z-score (no of sd measurements below age-matched mean BMD
144
Investigations
Paget's disease of bone
1. Bloods: high ALP, normal Ca/PO4;
2. bone radiographs: enlarged, deformed bones, lytic/sclerotic appearance, lack of distinction between cortex and medulla,
1. skull changes: osteoporosis circumscripta, enlargment of frontal and occipital areas, cotton wool appearance;
3. Bone scan: asessses extent of skeletal involvement, pagetic bone lesions are seen as areas with markedly increased uptake;
4. Resorption markers: monitors disease activity, check urinary hydroxyproline
145
Investigations
Paracetamol OD
1. Measure paracetamol levels - peak after 4hrs of ingestion
2. FBC, U+Es, glucose, LFTs, clotting screen, lactate, ABG
146
Investigations
Parkinson's disease
1. Clinical dx,
2. Levodopa trial (timed walking and clinical assessment),
3. bloods (serum caeruloplasmin - rule out wilson's disease as a cause of PD),
4. CT/MRI brain (exclude other causes of gait decline);
5. DA transporter scintigraphy (reduction in striatum and putamen
147
Investigations
PCOS
1. Bloods: high LH/LH:FSH ration/testosterone, androstenedione and DHEAS, low sex hormone binding globulin;
2. others:
1. hyperprolactinaemia,
2. hypo/erthyroidism,
3. CAH (17OHP levels),
4. cushing's syndrome;
5. impaired glucose tolerance:
6. FBG and HbA1c;
7. fasting lipid profile;
3. transvaginal USS for ovarian follicles and increase in ovarian volume
148
Investigations
Peptic ulcer disease and gastritis
1. Bloods: FBC, serum amylase, U+Es, clotting screen, LFT, cross match if active bleeding, secretin test if Z-E syndrome suspected - IV secretin causes rise in serum gastrin in these pts
2. Endoscopy - to rule out malignancy; duodenal not needed
3. Rockall scoring: severity after GI bleed, \<3 good prognosis, \>8 high risk of mortality
4. C13 urea breath test; serology (IgG against H pylori confirms exposure to H pylori but not eradication);
1. campylobacter-like organism test - colour change indicates HP
149
Investigations
Pericarditis
1. ECG - saddle STE;
2. Echo - pericardial effusion and cardiac function;
3. Bloods - FBC, U&Es, ESR/CRP, cardiac enzymes (normal), blood cultures/ASO titres/ANA/RhF for cause;
4. CXR - normal, may be globular
150
Investigations
Perineal abscess and fistula
1. Bloods: FBC, CRP, ESR, blood culture
2. MRI
3. Endoanal US
151
Investigations
Peripheral vascular disease
1. Full CV risk assessment = BP, FBC, FBG, lipid levels, ECG, thrombophilia (\<50yrs);
2. Colour duplex US showing site and degree of stenosis;
3. MRI/CT (extent and location of stenosis);
4. Ankle brachial pressure index -\> marker of CVD, \<0.8 = do not apply a pressure bandage as it worsens ischaemia
152
Investigations
Peritonitis
1. bloods: FBC, U+Es, LFTs, amylase, CRP, clotting, x-match, blood cultures, pregnancy test, ABG
2. Imaging: erect CXR, AXR, USS/CT abdo, laparoscopy
3. If ascites: ascitic tap and cell count;
4. SBP: \>250 neutrophils/mm3;
5. gram stain and culture
153
Investigations
Phaeo
1. 24hr urine collection for catecholamine levels and fractionated metanephrine levels;
2. plasma free metanephrines;
3. tumour localisation (MRI/CT), I-MIBG scintigraphy;
4. screen for asociated conditions;
5. genetic testing
154
Investigations
Pilonidal sinus
1. None needed;
2. bloods for sx of infections: raised WCC, fasting glucose
155
Investigations
Pneumoconiosis
1. CXR:
1. simple = micronodular mottling,
2. complicated = nodular opacities in upper lobes / micronodular shadowing / eggshell calcification of hilar lymph nodes / bilat lower zone retculonodular shadowing and pleural plaques;
2. CT scan = fibrotic changes can be visualised early;
3. bronchoscopy = visualisation and bronchoalveolar lavage;
4. LFT = restrictive
156
Investigations
Pneumonia
1. Bloods = FBC (^WCC), U&Es, LFT, blood cultures, ABG, blood film (mycoplasma = agglutination of RBC);
2. CXR = lobar/patchy shadowing, pleural effusion;
3. sputum/pleural fluids;
4. urine (pneumococcus and legionella Ag);
5. atypical viral serology;
6. bronchoscopy, bronchoalveolar lavage
157
Investigations
Pneumothorax
1. CXR -\> dark film area with no vascular markings, fluid level may be seen if bleeding;
2. ABG to check for hypoxaemia
158
Investigations
Polycythaemia
1. For Dx: FBC: high Hb, Hct, low MCV;
2. isotope dilution techniques: allows confirmation of plasma volume and red cell mass, distinguishes between relative and absolute pc
3. Pc rubra vera: high WCC, hgih platelets, low serum EPO, JAK2 mutation, bone marrow trephine and biopsy shows erythroid hyperplasia and raised megakaryocytes
4. 2ry pc: high serum EPO, exclude chronic lung disease/hypoxia, check for EPO secreting tumours
159
Investigations
Polymyalgia Rheumatica
1. ESR/CRP - raised; U+Es, FBC, LFTs, bone profile, protein electrophoresis, TFTs, creatine kinase;
2. other: urinary bence jones proteins, auto-Ab
160
Investigations
Polymyositis and dermatomyositis
1. PM:
1. creatine kinase up to 50x higher;
2. EMG;
3. muscle biopsy;
4. autoAb (myositis specific Ab, anti-Jo-1 Ab),
5. enzymes (SGOT, SGPT, LDH)
2. DM:
1. CK not as reliable as PM;
2. enzymes may be raised;
3. auto Ab: ANA, anti-Mi-2, Anti-Jo-1 (more in PM); EMG, helpful but normal too;
4. muscle biopsy
161
Investigations
Portal HTN
1. Bloods: LFTs, U+Es, blood glucose, FBC, clotting screen
2. Specific tests: ferritin - haemochromatosis, hepatitis serology, autoAb, a1-antitrypsin levels, caeruloplasmin - wilson's disease
3. Imaging: abdo US, doppler Us, CT/MRI, endoscopy (oesophageal varices); measure hepatic venous pressure gradient; liver biopsy
162
Investigations
Primary biliary cirrhosis
1. Bloods: LFT -\> high ALP+GGT, bilirubin high/ormal;
2. ALT/AST normal initially then increase as cirrhosis develops;
3. clotting: prolonging PT;
4. Antimitochondrial Ab, high IgM/cholesterol;
5. TFTs as associated with AI thyroid disease
6. USS: exclude extrahepatic biliary obstruction
7. Liver biopsy: chronic inflammatory cells and granulomas, destruction of bile ducts, fibrosis and regenerating nodules of hepatocytes
163
Investigations
Primary sclerosing cholangitis
1. Bloods: LFTs - high ALP and GGT, mildly elevated ALT and AST, low albumin, high bilirubin
2. serology: IgG high in children, IgM high in adults, ASMA/ANA in 30%, Anti-mitochondrial Ab ABSENT, pANCA present in 70%
3. ERCP: stricturing and interdispersed dilation of intrahepatic and extrahepatic bile ducts, small diverticuli on common bile duct may be seen
4. MRCP: enables non-invasive imaging of biliary tree
5. Liver biopsy: confirm dx and allows staging
164
Investigations
Prolactinoma
1. Exclude pregnancy;
2. TFTs: hypothyroidism, high TRH which stim prolactin release;
3. serum prolactin level (\>5000mU/L suggests true prolactinoma;
4. MRI;
5. assessment of pit function
165
Investigations
Prostate cancer
1. Bloods = FBC, U+Es, PSA (not very specific), acid phosphatase, LFTs, bone profile;
2. CT/MRI for local invasion/LN involvement;
3. transrectal US and needle biopsy;
4. isotope bone scan
166
Investigations
Pseudogout
1. Bloods: high WCC in acute attacks, high ESR, blood culture for exclusion of septic arthritis;
2. joint aspiration: rhomboid, brick shaped crystals, positive birefringence, culture/gram staining to exclude septic arthritis;
3. Plain radiograph of joint: chondrocalcinosis,
4. sx of OA: loss of joint space, osteophytes, subchondral cysts, sclerosis
167
Investigations
Psoriasis
1. Most pts don't need investigations;
2. guttate - anti-streptolysin-O titre, throat swab
3. Flexural psoriasis: skin swabs to exclude candidiasis
4. Nail clipping analysis for onychomycosis (fungal infection)
5. Joint involvement and analysed by checking for RhF and radiographs
168
Investigations
Pulm embolism
1. Well's score used to determine the best investigations = low probability with Wells \<4 = d-dimer; high probability with Wells \>4 = imaging (CTPA). Others:
2. bloods = ABG, thrombophilia screen
3. ECG = normal/tachy, right acis deviation or RBBB/ S1Q3T3 pattern
4. CXR = normal but helps exclude other dx.
5. Spiral CT pulm angiogram = 1st line investigation; poor sensitivity for small emboli, very for med-large emboli
6. VQ scan = indicates area of infarcted lung
7. Pulm angiography = invasive, rarely necessary
8. Doppler US of lowe limb
9. Echo
169
Investigations
Pulm HTN
1. CXR - exclude other lung diseases;
2. ECG RV hypertrophy and strain; pulm function tests;
3. LFTs (liver damage =\> portal HTN);
4. lung biopsy (interstitial lung disease);
5. echo assess RV function;
6. right heart catheterisation - directly measure pulm pressure and confirm diagnosis
170
Investigations
Reactive arthritis
1. Bloods: FBC, high ESR and CRP, HLA-B27 testing;
2. stool/urethral swab and cultures (may be -ve as post infection), urine (chlamydia), plain XR for chronic cases and for erosions at entheses;
3. joint aspiration excluding septic/crystal arthritis
171
Investigations
Rectal prolapse
1. Imaging: proctosigmoidoscopy, defecating proctogram or barium enema
2. Other: anal sphincter manometry, pudendal nerve studies
3. Sweat chloride test to check for CF
172
Investigations
Renal artery stenosis
1. Non-invasive = duplex US, US measurement of kidney size;
2. CT angiogram/MR angiography = risk of contrast nephrotoxicity;
3. Digital subtraction angiography = gold standard;
4. renal scintigraphy = radioagent that is either excreted by glomerular filtration or by the tubules, addition of an ACEi causes delayed clearance by affected kidney
173
Investigations
Renal cell cancer
1. Urinalysis (haematuria, cytology),
2. Bloods (FBC, U&Es, Ca, LFTs, High ESR (75%)),
3. abdo USS (best first line),
4. CT/MRI for staging
174
Investigations
Rheumatoid arthritis
1. Bloods: FBC (low Hb, high platelets), High ESR/CRP; RhF (70% of pts - asso. with Rh nodules and extraarticular manifestations) ANA (30%)
2. Joint aspiration: to rule out septic arthritis
3. Joint XR: Deformity, Osteopaenia, Narrowing of joint space, Soft tissue swelling
175
Investigations
Sarcoidosis
1. Bloods: high serum ACE, high Ca, high ESR, FBC - WCC low due to lymphocyte sequestration in lungs;
2. Ig - polyclonal hyperglobulinaemia, LFTs - high ALP and GGT
3. 24hr urine - hypercalciuria
4. CXR:
1. stage 0 - clear;
2. 1 - bilat hilar lymphadenopathy;
3. 2 1+ pulm infiltration and paratracheal node enlargement;
4. 3 - pulm infiltration and fibrosis
5. High res CT - diffuse lung involvement
6. Gallium scan for inflammation
7. Pulm function tests low FEV1, FVC is restrictive picture
8. Bronchoscopy and BA lavage - high lymphocyes, high CD4:CD8 ratio
9. Transbronchial lung biopsy: non-caseating granulomas consisting of: epithelioid cells, multinucleate langerhans cells, mononuclear cells
176
Investigations
SIADH
1. Low serum Na, creatinine, glucose/serum protein/lipids to rule out pseudohypoNa;
2. free T4 and TSH, short synacthen test
3. SIADH dx: low plasma osmolality, low serum Na conc, high urine osm, high urine Na -\> absence of hypovolaemia, oedema, renal failure, adrenal insufficiency and hypothyroidism for dx;
4. investigations for identifying the cause (CXR, CT, MRI)
177
Investigations
Sicke cell disease
1. Bloods: FBC - low Hb, reticulocytes: high in haemolytic crises, low in anaplastic crises, U+Es
2. Blood film: sickle cells, anisocytosis, features of hyposplenism: target cells, howell-jolly bodies
3. Sickle solubility test: dithionate is added to blood, increased turbidity
4. Hb electrophoresis - shows HbS, absence of HbA, high HbF
5. Hip XR: femoral head is common site of avascular necrosis
6. MRI/CT head: neurological complications
178
Investigations
Sjogren's syndrome
1. Bloods: high ESR and amylase (salivary glands);
1. Auto Ab: RhF, ANA, anti-ENA, Schirmer's test (+ve if \<10mm of filter paper wet after 5 min);
2. fluorescein/rose bengal stains - punctuate/filamentary keratitis
3. other investigations: reduced parotid salivary flow rate, reduced uptake/clearance isotope scan
4. biopsy - salivary/labial glands
179
Investigations
SLE
1. Bloods: FBC, U+E, LFT, Raised ESR, normal CRP, clotting, complement
2. autoAb: anti-dsDNA (60%), RhF (30%), anti-ENA/RNP/SM/Ro/La/histone/cardiolipin
3. Urine - haematuria, proteinuria, red cell casts
4. Joints - plain radiographs
5. Heart and lungs - CXR, ECG, echo, CT
6. Kidneys - renal biopsy
7. CNS - MRI scan, LP
180
Investigations
Spinal cord compression
1. Radiology: lat radiographs of spine to look for loss of alignment, features etc, MRI/CT;
2. Bloods: FBC, U+E, Calcium, ESR, Ig electrophoresis (multiple myeloma);
3. urine for Bence Jones proteins in Multiple Myeloma
181
Investigations
Spontaneous bacterial peritonitis
1. Paracentesis - if fluid has neutrophils \>250 cells/mm3, with no known reason for it
182
Investigations
Squamous cell carcinoma
1. Skin biopsy - confirm malignancy and type
2. FNA/LN biopsy: if mets suspected
3. Staging - CT, MRI, PET
183
Investigations
Stroke
1. Bloods for clotting profile;
2. ECG for arrhythmias;
3. EchoCG for cardiac thrombus, endocarditis and other cardiac sources of embolism;
4. carotid doppler US for carotid disease;
5. CT head scan for haemorrhages;
6. MRI brain for infarction sensitive imaging;
7. CT cerebral angiogram for dissections/stenosis
184
Investigations
SVT
1. ECG: differentiating AVNRT and AVRT - once the SVt has been terminated and normal rhythm are reestablished = AVNRT appears normal, AVRT delta waves (slurred upstroke of QRS); 24h ECG monitoring
2. Cardiac enzymes: check for MI features
3. Electrolytes - arrhythmia
4. TFTs - arrhythmia
5. Digoxin level
6. Echo - structural heart disease
185
Investigations
T2DM
1. Dx if one or more present:
2. syx of DM and random plasma glucose of \>11.1mmol/L, fasting plasma glucose \>7, 2-hr plasma glucose \>11.1 after 75g oral glucose tolerance test;
3. Monitor: HbA1c, U+Es, lipid profile, eGFR, urine albumin (creatinine ratio)
186
Investigations
TB
1. Sputum/pleural fluid/bronchial washing, tuberculin tests, mantoux test, heaf test;
2. INF-g test, HIV testing, CT, LN, pleural biopsy, sampling of other affected systems,
3. CXR=
1. 1ry = peripheral consolidation, hilar lymphadenopathy
2. Miliary = fine shadowing
3. Post-1ry = upper lobe shadowing, streaky fibrosis and cavitation, callcification, pleural effusion, hilar lymphadenopathy
187
Investigations
Testicular cancer
1. Bloods: FBC, U+E, LFTs, Tumours (alpha-fetoprotein, beta-HCG, LDH
2. Urine pregnancy test - +ve if tumour produces b-HCG
3. CXR for lung mets
4. Testicular USS: visualisation, associated hydrocoele
5. CT abdo and thorax: allows staging -\> royal marsden hospital staging
188
Investigations
Thalassaemia
1. Bloods: FBC - low Hb, low MCV, low MCH
2. Blood film: hypochromic microcytic anaemia, target cells, nucleated red cells, high reticulocyte count
3. Hb electrophoresis: absent or reduced HbA, high hbF
4. Bone marrow: hypercellular, erythroid hyperplasia
5. Genetic testing
6. Skull XR - hair on end appearance in beta thalassaemia major, caused by expansion of marrow into cortex
189
Investigations
Thyroid cancer
1. Bloods: TFTs, bone profile, tumour markers (thyroglobulin - pap and follicular;
2. calcitonin - medullary);
3. Fine-needle aspiration cytology allows historical dx;
4. excision LN biopsy (cervical lymphadenopathy);
5. isotope scan,
6. CT/MRI for staging
190
Investigations
Thyroid nodules
1. TFTs (euthyroid),
2. US (character of nodules),
3. FNA (cytological analysis),
4. Radionuclide isotope scanning (iodine uptake),
5. CT/MRI
191
Investigations
Thyroiditis
1. Based on clinical observations;
2. histology: diffuse lymphocytic and plasma cell infiltration with formation of lymphoid follicles;
3. TSH raised;
4. antibodies: anti-TPO and anti-thyroglobulins' thyroid US, radionuclide isotope scanning
192
Investigations
Tonsillitis
1. Throat swabs and rapid antigen tests can be performed but NOT recommended;
2. swabs may not be able to distinguish between infection and colonisation
193
Investigations
Tranisent Ischaemic attack
1. 1ry care investigations: urinalysis, FBc, U+Es, lipids, LFTs, TSH, ECG (may show AF/previous MI);
2. 2ry care: unenhanced CT may show haemorrhage;
3. investigate for source of emboli: ECG (24hr tape or cardiac monitoring may be considered if paroxysmal AF is suspected), doppler US of carotid and vertebral arteries
194
Investigations
Tricuspid regurg
1. Bloods: FBC, LFT, Cardiac enzymes and blood cultures;
2. ECG: P pulmonale (right atrial hypertrophy);
3. CXR: RHS enlargement of cardiac shadow;
4. Echo: extent of regurg estimated using doppler US (may show valve prolapse and RV dilation);
5. Right heart catheterisation: useful for assessing pulm artery pressure
195
Investigation
Subarachnoid haemorrhage
1. Bloods: FBC, U+Es, ESR/CRP, clotting;
2. CT scan hyperdense areas in basal regions of skull due to blood;
3. angiography for bleeding;
4. LP = increased opening pressure, increased red cells, **_xanthochromia_** - straw coloured due to breakdown of RBC
196
Investigations
Ulcerative colitis
1. Bloods: FBC - low Hb, high WCC; high ESR or CRP, low albumin
2. Stool: infectious colitis is DDx so stool culture useful;
3. faecal calprotectin allows differentiation of of IBS from IBD
4. AXR: rule out toxic megacolon
5. Flexible sigmoidoscopy/colonoscopy: determines severity, histological confirmation, detection of dysplasia
6. Barium enema: mucosal ulceration with granular appearance and filling defects, narrow colon, loss of haustral pattern - leadpipe appearance - colonoscopy may be dangerous during acute exacerbation - risk of perf
197
Investigations
Urticaria
1. Usually clinical - tests may be required for chronic urticaria - FBC, ESR/CRP, patch testing, IgE test
198
Investigations
UTI
1. Urine dipstick (+ve leucocyte esterase and nitirites),
2. urine microscopy (presence of leucocytes = infection),
3. urine culture (exclude dx/if pt failed to respond to empirical Abx),
4. US (rule out obstruction),
5. bloods (FBC, U&Es, CRP, Blood cultures)
199
Investigations
Varicose veins
Duplex US -\> sites of incompetence/reflux, allows exclusion of DVT
200
Investigations
Vascuitides
1. Bloods: FBC: normocytic anaemia, high platelets, high neutrophils, high ESR/CRP;
2. AutoAb: cANCA in wegner's;
3. urine: haematuria, proteinuria, red cell casts;
4. CXR: diffuse, nodlar or flitting shadows, atelectasis;
5. biopsy: renal, lung, temporal artery;
6. angiography: id aneurysms
201
Investigations
Ventricular fibrillation
1. ECG, cardiac enzyme (recent ischaemic event);
2. electrolytes - arrhythmias and VF;
3. drug levels and toxicology screen - anti-arrhythmics and cocaine can cause arrhythmia;
4. TFTs - hyperthyroidism can cause tachyarrhythmias, coronary angiography (after VF survival check coronary arteries)
202
Investigations
Ventricular tachycardia
1. ECG -\> VT vs SVT with aberrant conduction -\> rate \>100bpm, broad QRS complexes, AV dissociation;
2. electrolytes,
3. drug levels (digoxin toxicity),
4. cardiac enzyme (ischaemic event)
203
Investigations
Viral Hep A and E
1. Bloods: LFTs - high ALT/AST/ALP and bilirubin, high ESR, low albumin, high platelets
2. Vital serology:
3. hep A: anti-HAV IgM (after 3-5m disappears), anti-HAV IgG (recovery phase and lifelong persistence)
4. Hep E: anti-HEV IgM (raised 1-4wks after onset); anti-HV IgG
5. Urinalysis: +ve for bilirubin, raised urobilinogen
204
Investigations
Viral Hep B and D
1. Viral serology: Acute HBv: HbsAg+ and IgM anti-HBcAg;
2. Chronic HBV: HBsAg +ve, IgG anti-HBcAg, HBeAg+/-;
3. HBV cleared/vaccinated: anti HBsAg Ab+, IgG anti HBcAg;
4. HDV infection: detected by IgM/G against HDV, PCR used for detection
5. LFTs: high AST/ALT/ALP/bilirubin
6. Clotting: high PT (severe disease)
7. Liver biopsy
204
Investigations
Viral Hep C
1. Bloods: HCV serology: anti-HCV Ab - IgM(acute) IgG (chronic);
2. reverse transcriptase PCR: allows detection and genotyping of HCV;
3. LFT: acute - high ALT/AS/bilirubin, chronic infection: 2-8x elevation of AST+ALT
4. Liver biopsy: assess degree of inflammation and liver damage, useful for dx cirrhosis
205
Investigations
Vit D deficiency and osteomalacia
1. Bloods: low/normal Ca, low PO4, high ALP, low 25OH vit D, high PTH, check U+Es, check ABG, increased PO4 excreting
2. Radiographs: may appear normal, may show OP, Looser's zones = wide transverse lucenies traversing part way through a bone, usually at right angles to the involved cortex and are associated most frequently with OM and rickets
3. Bone biopsy after double tetracycline labelling -\> tetracycline deposited at the mineralisation front as a band;
1. after 2 courses of tetracycline, the distance between the bands of deposited tetracycline is reduced in OM;
2. not usually necessary for the dx of OM
205
Investigations
Vit B12 deficiency
1. Serum B12 is not very accurate/reliable, other new tests: plasma total homocysteine, plasma methylmalonic acid, holotranscobalamin
2. FBC and blood film: hyperegmented neutrophils, oval macrocytes, circulating megaloblasts
3. Pernicious anaemia tests: anti-IF Ab, anti-parietal cell Ab, schilling test
206
Investigations
Volvulus
1. AXR, erect CXR if perf suspected;
2. water soluble contrast enema, shows site of obstruction;
3. CT scan
207
Investigations
von Willebrand disease
1. Bleeding time - high;
2. APTT: high,
3. Factor VIII - low,
4. vWF - low,
5. ristocetin cofactor (reduced platelet aggregation by vWF in presence of ristocetin)
208
Investigations
Wernicke's encephalopathy
1. Dx mainly based on hx and exam;
2. possible: FBC (high MCV common in alcoholics), U+Es (exclude met imbalance as confusion), LFTs, glucose, ABG (hypercapnia and hypoxia can confuse), serum thiamine;
3. CT head useful
209
Investigations
Wilson's disease
1. Bloods: LFTs = high AST/ALT/ALP;
2. low serum caeruloplasmin (acute phase protein, false negative if underlying infection),
3. serum copper
4. 24hr urinary Cu levels increased in wilson's disease
5. Liver biopsy: increased copper content
6. Genetic analysis: wilson's wide variety of gene mutations so there isn't a simple genetic test that can be done
210
Investigations
Wolff-Parkinson-white syndrome
1. ECG may be normal if conduction speed matched bundle of His = short PR interval, broad QRS complex, slurred upstroke producing delta wave;
2. pt may be in SVT (AVRT),
3. bloods check for other causes of arrhythmia,
4. echo for structural heart defects
211
Investigation
Systemic sclerosis
1. AutoAb: ANA, anti-centromere (70%), anti-topoisomerase II (30%), anti-nucleolar, anti-RNA polymerase;
2. lung: CXR, pulm function tests, CT;
3. heart: ECG, echo;
4. GI: endoscopy, barium studies;
5. kidneys: U+Es, creatinine clearance;
6. neuromusc: EMG, biopsy; joints: radiography;
7. skin: biopsy
212
Investigation
Urinary Tract Calculi
1. Bloods = FBC (high WCC), U&Es, calcium, urate, phosphate;
2. urine = dipstick (haematuria common), MC&S;
3. XR KUB;
4. IV urography,
5. US,
6. non-enhanced spiral CT,
7. isotope radiography
213
Investigation
Varicella zoster
1. Usually clinical dx;
2. vesicle fluid may be sent for electron microscopy viral PCR (RARE);
3. chicken pox in adult with PMH of varicella infection = HIV test
