Items in AFP with MESH term: Magnetic Resonance Imaging
ABSTRACT: Dementia is a common disorder among older persons, and projections indicate that the number of patients with dementia in the United States will continue to grow. Alzheimer's disease and vascular dementia account for the majority of cases of dementia. After a thorough history and physical examination, including a discussion with other family members, a baseline measurement of cognitive function should be obtained. The Mini-Mental State Examination is the most commonly used instrument to document cognitive impairment. Initial laboratory evaluation includes tests for thyroid-stimulating hormone and vitamin B12 levels. Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging also is recommended. Other testing should be guided by the history and physical examination. Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis. Neuropsychologic testing may be most helpful in situations where screening tests are normal or equivocal, but there remains a high level of concern that the person may be cognitively impaired.
Evaluation of Palpable Breast Masses - Article
ABSTRACT: Palpable breast masses are common and usually benign, but efficient evaluation and prompt diagnosis are necessary to rule out malignancy. A thorough clinical breast examination, imaging, and tissue sampling are needed for a definitive diagnosis. Fine-needle aspiration is fast, inexpensive, and accurate, and it can differentiate solid and cystic masses. However, physicians must have adequate training to perform this procedure. Mammography screens for occult malignancy in the same and contralateral breast and can detect malignant lesions in older women; it is less sensitive in women younger than 40 years. Ultrasonography can detect cystic masses, which are common, and may be used to guide biopsy techniques. Tissue specimens obtained with core-needle biopsy allow histologic diagnosis, hormone-receptor testing, and differentiation between in situ and invasive disease. Core-needle biopsy is more invasive than fine-needle aspiration, requires more training and experience, and frequently requires imaging guidance. After the clinical breast examination is performed, the evaluation depends largely on the patient's age and examination characteristics, and the physician's experience in performing fine-needle aspiration.
ABSTRACT: Cirrhosis and chronic liver failure are leading causes of morbidity and mortality in the United States, with the majority of preventable cases attributed to excessive alcohol consumption, viral hepatitis, or nonalcoholic fatty liver disease. Cirrhosis often is an indolent disease; most patients remain asymptomatic until the occurrence of decompensation, characterized by ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal bleeding from portal hypertension. Physical examination of patients with cirrhosis may reveal a variety of findings that necessitate a hepatic- or gastrointestinal-based work-up to determine the etiology. Some patients already may have had laboratory or radiographic tests that incidentally uncovered signs of cirrhosis and its comorbidities. No serologic or radiographic test can accurately diagnose cirrhosis. A significant correlation has been demonstrated between persistently elevated liver function tests and biopsy-proven underlying hepatic disease; thus, a more targeted serologic work-up is indicated in patients whose liver function test results are persistently abnormal. Unnecessary medications and surgical procedures should be avoided in patients with cirrhosis. Referral for liver biopsy should be considered only after a thorough, non-invasive serologic and radiographic evaluation has failed to confirm a diagnosis of cirrhosis; the benefit of biopsy outweighs the risk; and it is postulated that biopsy will have a favorable impact on the treatment of chronic liver disease.
Noninvasive Cardiac Imaging - Article
ABSTRACT: Noninvasive cardiac imaging can be used for the diagnostic and prognostic assessment of patients with suspected or known coronary artery disease. It is central to the treatment of patients with myocardial infarction, coronary artery disease, or acute coronary syndromes with or without angina. Radionuclide cardiac imaging; echocardiography; and, increasingly, cardiac computed tomography and cardiac magnetic resonance imaging techniques play an important role in the diagnosis of coronary artery disease, which is the leading cause of mortality in adults in the United States. Contemporary imaging techniques, with either stress nuclear myocardial perfusion imaging or stress echocardiography, provide a high sensitivity and specificity in the detection and risk assessment of coronary artery disease, and have incremental value over exercise electrocardiography and clinical variables. They also are recommended for patients at intermediate to high pretest likelihood of coronary artery disease based on symptoms and risk factors. Cardiac magnetic resonance imaging and cardiac computed tomography are newly emerging modalities in the evaluation of patients with coronary artery disease. Cardiac magnetic resonance imaging is useful in the assessment of myocardial perfusion and viability, as well as function. It also is considered a first-line tool for the diagnosis of arrhythmogenic right ventricular dysplasia. Cardiac computed tomography detects and quantifies coronary calcium and evaluates the lumen and wall of the coronary artery. It is a clinical tool for the detection of subclinical coronary artery disease in select asymptomatic patients with an intermediate Framingham 10-year risk estimate of 10 to 20 percent. In addition, cardiac computed tomography is evolving as a noninvasive tool for the detection and quantification of coronary artery stenosis. Although guidelines can help with treating patients, treatment ultimately should be tailored to each person based on clinical judgment of the a priori risk of a cardiac event, symptoms, and the cardiac risk profile.
ABSTRACT: Chronic foot pain is a common and often disabling clinical complaint that can interfere with a patient's routine activities. Despite careful and detailed clinical history and physical examination, providing an accurate diagnosis is often difficult because chronic foot pain has a broad spectrum of potential causes. Therefore, imaging studies play a key role in diagnosis and management. Initial assessment is typically done by plain radiography; however, magnetic resonance imaging has superior soft-tissue contrast resolution and multiplanar capability, which makes it important in the early diagnosis of ambiguous or clinically equivocal cases when initial radiographic findings are inconclusive. Computed tomography displays bony detail in stress fractures, as well as in arthritides and tarsal coalition. Bone scanning and ultrasonography also are useful tools for diagnosing specific conditions that produce chronic foot pain.
ABSTRACT: Hematuria, symptomatic and incidental, that involves more than three red blood cells per high-power field on two of three properly collected urinalysis specimens warrants some type of imaging to evaluate the upper tracts. Traditionally, excretory urography or the intravenous pyelogram has been the mainstay of the hematuria work-up, but computed tomography urography has more recently been recognized to have significant advantages. Multidetector computed tomography urography, a cross-sectional technique, is less susceptible to overlying bowel gas and more sensitive for detection of small tumors and calculi. Moreover, intravenous-pyelogram-like images can be obtained by using reconstruction techniques. In specific cases, ultrasound examination and magnetic resonance imaging can also be useful, and are particularly helpful in children and pregnant women. Neither modality has the sensitivity of computed tomography for calculi, but small tumors may be visible on magnetic resonance imaging. This article reviews the appropriateness criteria for the various radiologic imaging tests used in the evaluation of hematuria, as proposed by the American College of Radiology.
ABSTRACT: Acute monoarthritis can be the initial manifestation of many joint disorders. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive. Examination of joint fluid often is essential in making a definitive diagnosis. Leukocyte counts vary widely in septic and sterile synovial fluids and should be interpreted cautiously. If the history and diagnostic studies suggest an infection, aggressive treatment can prevent rapid joint destruction. When an infection is suspected, culture and Gram staining should be performed and antibiotics should be started. Light microscopy may be useful to identify gout crystals, but polarized microscopy is preferred. Blood tests alone never confirm a diagnosis, and radiographic studies are diagnostic only in selected conditions. Referral is indicated when patients have septic arthritis or when the initial evaluation does not determine the etiology.
ABSTRACT: A detailed history alone may lead to a specific diagnosis in approximately 70 percent of patients who have wrist pain. Patients who present with spontaneous onset of wrist pain, who have a vague or distant history of trauma, or whose activities consist of repetitive loading could be suffering from a carpal bone nonunion or from avascular necrosis. The hand and wrist can be palpated to localize tenderness to a specific anatomic structure. Special tests can help support specific diagnoses (e.g., Finkelstein's test, the grind test, the lunotriquetral shear test, McMurray's test, the supination lift test, Watson's test). When radiography is indicated, the posterior-anterior and lateral views are essential to evaluate the bony architecture and alignment, the width and symmetry of the joint spaces, and the soft tissues. When the diagnosis remains unclear, or when the clinical course does not improve with conservative measures, further imaging modalities are indicated, including ultrasonography, technetium bone scan, computed tomography, and magnetic resonance imaging. If all studies are negative and clinically significant wrist pain continues, the patient may need to be referred to a specialist for further evaluation, which may include cineroentgenography, diagnostic arthrography, or arthroscopy.
ABSTRACT: The American College of Radiology has developed appropriateness criteria for a number of clinical conditions and procedures. Criteria are available on imaging tests used in the evaluation of acute chest pain--suspected myocardial ischemia. Imaging tests for a suspected cardiac etiology include transthoracic echocardiography, transesophageal echocardiography, radionuclide perfusion imaging, radionuclide ventriculography, radionuclide infarct avid imaging, and positron emission tomography. If the cardiac ischemic work-up is negative or indeterminate, applicable tests include chest radiography; conventional, multidetector, and electron beam computed tomography; and magnetic resonance imaging. A summary of the criteria, with the advantages and limitations of each test, is presented in this article.
ABSTRACT: Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.