Table of contents :

Imaging of inner structures  Structural imaging visible light inspection endoscopy palpation percussion X-rays computed tomography (CT) spectrophotometry Functional imaging sounds ultrasounds (US) X-rays electrical activity electrocardiogram (EKG) electroencephalogram (EEG) electrical impedance pressure into closed containers temperature

humidity capture of molecules pH monitoring scintigraphy radioimmunoscintigraphy (RIS) SPECT positron emission tomography (PET) magnetic resonance imaging (MRI) optical topography (OT) magnetoencephalography (MEG) electronic nose flows Collection of samples Molecular labeling Surgical operations Experimental animal models : main model organisms for Homo sapiens morphological imaging : phenotype alterations production of pAbs in allogeneic organisms

• projection : reduction of dimensionality
• 2D maximum intensity projection (MIP) : a 3D image (x/y/z) projected into the x/y plane by assignign the maximum intensity that can be found along the z axis at each x/y position to a single projection image. A processing method for MRA images. A MIP is a record of a maximum intensity ray (generated through a mathematical algorithm) as it passes through an angiographic volume. Each point in an MIP represents the highest intensity experienced in that location on any partition within the imaging volume
• tomograms
• transverse or (trans)axial scan (seen from feet) : a plane, slice or section made by cutting the body or part of it at right angles to the long axis. If the body or part is upright, the cut would be parallel to the horizon
• lateral or sagittal scan (LS) : a plane, slice or section of the body cutting from front to back through the saggital suture of the skull, and continued down through the body in the same direction, dividing it into 2 parts, then turning one half to view it from its cut surface.
• US : head at left and feet at right
• MRI : head upward and feet downward
• coronal or frontal scan (seen from front side) : a plane, slice or section made by cutting across the body from side to side and therefore parallel to the coronal suture of the skull.
• oblique scan
• acquisition : the process of measuring and storing image data
• acquisition matrix : the total number of independent data samples in the frequency (f) and phase (f) directions
• K-space : a data acquisition matrix containing raw image data prior to image processing. In 2DFT, a line of data corresponds to the digitized NMR signal at a particular phase-encoding level.
• acquisition time : the period of time required to collect the image data. This time does not include the time necessary to reconstruct the image
• analogic (pellicle; base unit = granule)
• digital (computer; base unit  = pixel (2D) or voxel (3D)), eg. :
• X-rays (e.g. digital radiography, digital fluoroscopy, CT, digital angiography)
• echography
• MRI
• nuclear medicine
Image reconstruction : the mathematical process of converting the composite signals obtained during the data acquisition phase into an image.
Advantages over analogic rilevation :
• gating : timing the acquisition of data to physiological motion in order to minimize motion artifacts (e.g., cardiac gating, respiratory gating)
• archiviation
• matrices :
• 256x256 pixels
• 512x512 pixels
• 1024x1024 pixels
• size of the pixel = field of view (FOV) / (number of pixels)
• every single gray tonalitiy is given a binary number
• with 8 bit per pixel (= 1 byte) you can write 256 different binary numbers and then you can assign a number to any of 256 different gray tonalities
• with 16 bit per pixel you can compose 65536 different binary numbers (used in MRI)
• total information content  = (bit per pixel) x (number of pixels in the matrix)
• elaboration / postprocessing
• visualization :
• gray-scale inversion
• image subtraction
• zoom
• punctual zoom enlarges all pixels
• local zoom (bilinear interpolation maintains the original size of the pixel)
• windowing applies the 16-gray scale within restricted areas containing only a few tonalities.
• advanced postprocessing :
• 2D reformattation
• 3D reformattation
• virtual endoscopy
• virtual colonoscopy : pneumocolon => 2D imaging, simulation of double contrast-enhanced X-rays, external visualization or colonoscopy with prospective vision. It has 90% sensitivity for colonic polyps with diameter > 10 mm (80% for those sized < 10 mm).

Indications :
• screening of CRC in patients with familiarity of occult blood in stools
• intolerance to traditional colonoscopy
• distal colonic stenosis not passed by traditional endoscopy (e.g. in ulcerative colitis, or diverticular disease)
• preoperatory CRC staging
Preparatrion : 3 days of fiber-free diet, drink 4 L of cathartic iso-osmotic PEG solution the day before examination
Limitations : false positives due to fecal remnants
Web resources : 3-D Virtual Colonoscopy at State University of New York (SUNY) at Stony Brook
• virtual bronchoscopy

Web resources : Bronchoscopic Virtual and Real Imaging Tutorials at University of Iowa
• virtual angiography

Web resources : Virtual Endoscopy of the Coronary Arteries
Limitations :
• poor sensitivity for flat lesions
• inability to practice biopsy or therapeutical treatments
• high cost
• X-rays exposure
Web resources :
• Virtual Endoscopy Center (VEC) at Wake Forest University School of Medicine
• Department of Computer Science in Medicine at University of Hamburg
• 3D Medical Imaging Laboratory, Stanford University, School of Medicine, Department of Radiology
• Coloring Internal Cavities for Virtual Endoscopy
• Virtual Endoscopy Based on 3D MR Imaging Data Sets
• Virtual Endoscopy Medical Application
• Virtual (computed) endoscopy : development and evaluation using the visible human datasets at Mayo Clinic
• ViewTec MedView
• Dept. of Computational Science and Engineering, Graduate School of Engineering, Nagoya University

Department of Computer Science, Fraunhofer Institute for Computer Graphics (IGD) at Darmstadt University of Technology
• Multidimensional Image Processing Lab, Pennsylvania State University
• Comprehensive Human Animation Resource Model (CHARM) project
• Network Oriented Visualisation In a Clinical Environment (NOVICE) project
• Image Guided Surgery at Traxtal Technologies
• The virtual temporal bone
• 3-D Lab at University of Copenhagen
• Virtual computed endoscopy
• Virtual Endoscopy Center
• Virtual Environment Technology Laboratory
• Virtual Reality in Medicine
• Virtual Reality: Medical Applications
• Vital Images of Parasinuses
• segmentation : the identification of objects above background noise using image-processing methods. Can be achieved by detecting either object boundaries (contour-orientated segmentation) or whole objects (region-based segmentation).
• surface reconstruction : visualization of surface polygons from arbitrary angles in a graphical viewer. Requires previous object identification using segmentation techniques
• volume rendering (VolRen): computer visualization of 3D images from arbitrary angles without explicit definition of surface geometry
• transmission :
• radio-frequency identification (RFID) tag contains a computer chip encoded with a unique identification number and a tiny antenna. To read the tag, a scanner that emits radio waves is waved over the chip. This is detected by the antenna, which generates a tiny electrical current in the chip and powers the tag into beaming back a radio signal that reveals the ID number. VeriChip, made by Applied Digital Solutions in Delray Beach, Florida, is the size of grain of rice and is injected under a patient's skin. On 13 October, the company announced that they had received approval from the Food and Drug Administration to market them in the United States. Applied Digital Solutions says that chips rooted in the skin could be used to pull up a patient's personal and medical records from a secure database. This could prove useful when, for example, someone is unconscious or has numerous records at different clinics that must be pulled together in an emergency. But privacy advocates argue that tagged bracelets or cards carrying medical information are just as effective as an implanted chip. They warn that the chips might ultimately find a use to compulsorily tag and track prisoners or visitors to a foreign country. RFID tags have been around for over 50 years, although many of them are larger, battery-powered and actively transmit data carried on their chips. Now the size of a grain of rice, the RFID tag has been around for 50 years. Over the last decade, smaller, cheaper 'passive' chips have been developed that only release information when scanned - and these chips are now poised to invade many aspects of our lives. Most people are already using RFID tags unawares: in security badges that allow access to buildings, or in keys that communicate with a car to allow only the driver in. Many companies are also starting to use the chips to track goods shipped from manufacturers to their destination, helping them keep precise track of where items are and avoid them being mislaid in warehouses. RFID tags are already routinely implanted in pets, so they can be identified if lost. But Applied Digital Solutions say that VeriChip is the first chip designed for use in people. Some people have already been tagged; the Attorney General of Mexico and some of his staff had chips implanted to limit access to a secure room.


• Surgichip (source : e4engineering.com) is programmed with critical information such as date of surgery, patient's full name, surgical site, a description of the operation to be performed, and the surgeon's name. The Surgichip itself can store 256 characters which allows a complete description of most procedures to be encoded on the chip (e.g., arthroscopic meniscus repair and anterior cruciate ligament reconstruction with patellar tendon allograft). In the unusual instance in which more than 256 characters are required, a second chip may be used. The chip may be programmed at the preoperative outpatient visit, in the emergency room, or on the hospital floor if the patient is an inpatient. A nurse or physician then scans the chip with an RFID reader and the patient reviews the information to be sure it is correct. The Surgichip reader itself prints in clear typed script rather than handwriting or hand printing which are occasionally illegible and may be misinterpreted.

 
Web resources : Association for Automatic Identification and Mobility, a trade group based in Warrendale, Pennsylvania
• videoconference allows tutoring for
• telemedicine : the provision of consultant services by off-site physicians to health care professionals on the scene, as by means of closed-circuit television.

Web resources : American Telemedicine Association (ATA)
• tele-mentoring is an interactive experimental method that allows young surgeons' education by distant learning tutoring of an expert surgeon. The problem about assessment of efficacy and quality of computer-assisted instruction is under evaluation today. Tele-mentoring is supported by videoconferencing system and it is not an exclusive methodology but an additional methodology to traditional didactic for clinicians and surgeons. It allows personal virtual trainings by computers and telecommunication systems
• teletriage :
• telesurgery : in the new minimally invasive surgical era, virtual reality, robotics, and image merging have become topics on their own, offering the potential to revolutionize current surgical treatment and assessment. Improved patient care in the digital age seems to be the primary impetus for continued efforts in the field of telesurgery. The progress in endoscopic surgery with regard to telesurgery is manifested by digitization of the pre-, intra-, and postoperative interaction with the patients' surgical disease via computer system integration: so-called Computer Assisted Surgery (CAS). The preoperative assessment can be improved by 3D organ reconstruction, as in virtual colonoscopy or cholangiography, and by planning and practicing surgery using virtual or simulated organs. When integrating all of the data recorded during this preoperative stage, an enhanced reality can be made possible to improve intra-operative patient interactions. CAS allows for increased three-dimensional accuracy, improved precision and the reproducibility of procedures. The ability to store the actions of the surgeon as digitized information also allows for universal, rapid distribution: i.e., the surgeon's activity can be transmitted to the other side of the operating room or to a remote site via high-speed communications links, as was recently demonstrated during the Lindbergh operation (7 Sept 2001 : a laparoscopic robotic cholecystectomy performed by surgeon Professor Jacques Marescaux in New York using the robot ZEUS^TM on a patient at the Hôpitaux Universitaires in the Institut de Recherche contre les Cancers de l'Appareil Digestif/European Institute of TeleSurgery (IRCAD/EITS) in Strasbourg (France)), appropriately dubbed after Charles Lindbergh flew non-stop across the Atlantic for the first time in history, aboard the “Spirit of St. Louis” in 1927. Strasbourg. Signals traveled a total of 14 000 kms, with an output of 10 Mbits per second and a constant delay of 150 ms (80 ms for the transfer of data and 70 ms for the decoding of the video image). 54 minutes later, the dream had become reality; a complete procedure had been performed with ease, without encountering any technical problems and without any perceptible delay in transmission : unfortunately the press release on 11 Sept 2001 was completely obscured by the Twin Tower tragedy. Furthermore, the surgeon will be able to share his expertise and skill through teleconsultation and telemanipulation, bringing the patient closer to the expert surgical team through electronic means and opening the way to advanced and continuous surgical learning. Finally, for postoperative interaction, virtual reality and simulation can provide us with 4 dimensional images, time being the fourth dimension. This should allow physicians to have a better idea of the disease process in evolution, and treatment modifications based on this view can be anticipated. They are presently determining the accuracy and efficacy of 4 dimensional imaging compared to conventional evaluations^{ref1, ref2}.

Web resources :
• European Institute of Telesurgery (EITS)
• MIT-HMSL telesurgery project
• telemetry : the making of measurements at a distance from the subject, the measurable evidence of the phenomena under investigation being transmitted by radio signals, wires, or other means
• biotelemetry : remote detection and measurement of a human or animal condition, activity, or function (as heartbeat or body temperature)
• radioelectrocardiography / radiocardiography : electrocardiography in which impulses are beamed by radio from the subject to a receiver close to or at a distance from the subject
• telefluoroscopy
• telecardiography : the recording of an electrocardiogram by transmission of impulses to a site at a distance from the patient.
• telecardiophone : an apparatus for rendering heart sounds audible to listeners at a distance from the patient
• Vital Positioning System (VPS)™ (source : Medical Intelligence, Quebec, Canada) a wireless Bluetooth-based cardiac alert system that is integrated into a cell phone or PDA and is linked to GPS. The system is designed to automatically alert emergency services as soon as it detects ischemic changes. The VPS system is miniaturized and comes with an elastic belt worn at the waist or abdomen using no adhesive. This belt integrates a wireless digital ECG, cardiac activity sensors, a small GPS and a simple Bluetooth transmitter (2.4 Ghz) that sends data to the phone or pocket pc. The belt can operate up to 100 yds. (300 ft) from the phone. The cellphone or pocket pc is inserted into a base that holds the VPS software, complementary telecommunications peripherals and artificial intelligence. The VPS system is miniaturized and comes with sensors (that could one day be subcutaneous) that send continuous ECG data to the patient’s cellphone or pocket pc. Using Windows, our cardiac data management system continuously stores data from our wireless digital ECG including exact times and results. This gives the treating physician and the patient a clearer picture of the activities leading to complications, thereby facilitating diagnosis and maximizing treatment. Far exceeding simple pulse rate, this system could have applications in a number of markets^ref.
• telepathology : the practice of pathology at a remote location by means of a high-resolution video monitor that displays an image transmitted over telephone lines from a remote-controlled microscope attached to a video camera. Telepathology, developed in partnership with the company Samba Technologies, is a real-time tele-expertise service that allows a doctor to be helped in his diagnosis by a distant anapathologist (anatomopathologist): the anapathologist can conduct, in real time, a remote microscopic examination of a tissue. For example, during a surgical operation, the surgeon takes a sample to have it analysed immediately by an anapathologist practising on another site. The consultant expert intervenes immediately as if he was present in the operating room. He carries out the examination on the operated piece, receiving the images, while communicating with the surgical team and he is immediately informed of the conclusions of his analysis. This system helps save precious time and enables him to immediately define the required operating strategy. The solution of tele-pathology can also be applied outside the context of a surgical procedure. It can favour the collaboration between laboratories, ease the transmission by avoiding sending samples by post or other methods, and therefore guarantee rapid and secure examinations
• telediagnosis : determination of the nature of a disease at a site remote from the patient on the basis of transmitted telemonitoring data or closed-circuit television consultation
• robotic tele-echography (TER) developed in partnership with the company Praxim and the laboratory TIMC of the university Joseph Fourier, allows an ultrasound expert to carry out a remote ultrasound scan on a patient present on another site. The specialist remotely controls a robot that is holding an ultrasound transducer and that brings back to him, in real time, not only the ultrasound scan images, but also the fine tactile sensations, an essential dimension for a sharper examination
• teleradiology : several hundred U.S. hospitals use overseas teleradiology services^{ref1, ref2}. Industry leaders, such as Teleradiology Solutions, NightHawk Radiology Services, and Virtual Radiologic, state that they adhere to the American College of Radiology (ACR) guidelines with respect to licensure, insurance, and hospital privileges. As for compensation, regulations of the Centers for Medicare and Medicaid Services (CMS) prohibit payments to providers outside the USA — an obstacle that many of the companies finesse by providing a "preliminary report," which is later followed by a U.S. radiologist's "final primary report." The overseas radiologists are paid directly (by the hospital or the local radiologists) at a rate of $50 to $75 per radiograph, whereas the local radiologists bill the payer. The ACR has voiced concern about this practice, because of the worry that some domestic radiologists are signing off on the "ghost-read" radiographs without carefully scrutinizing the films themselves. Although most international teleradiology companies have followed the ACR licensure and credentialing guidelines, in 2003, the Indian technology giant Wipro "tested the waters" (in the words of one Wipro executive) by using Indian radiologists who were neither licensed nor board-certified in the United States. The controversial experiment was subsequently suspended, but the potential for such practices remains. Although the ACR presents its teleradiology guidelines as quality-assurance measures (and quality is doubtless the organization's greatest concern), the possibility that low-wage foreign radiologists will take work from its members has surely entered its calculus. As one U.S. radiologist wrote on a popular professional Web log, "Who needs to pay us $350,000 a year if they can get a cheap Indian radiologist for $25,000 a year?" ^ref
• surgical tele-companionship : long distance collaboration between colleagues. The dimension of exchange and collaboration is at the centre of all the experiments conducted in telemedicine. In line with the experiment lead in 2001 during the Lindbergh operation, France Telecom is currently working with the Army's healthcare service on a solution of tele-companionship in surgery via satellite connection. The objective: to enable a specialised surgeon to bring his expertise to a colleague working on a remote site. When a population is on a remote site - for example on an island, an oil rig, an armed front, a ship… - only one surgeon can answer all the pathologies to which he might be confronted. The operating room located in the isolated area is equiped with robotised surgical material. The operation conducted by the local practitioner is accompanied remotely and in real time by the specialist. He guides his colleague's operating movements by remotely controlling the arms of the surgical robot.
• resolution
• time resolution
• spatial resolution : the ability to define minute adjacent objects/points in an image (ability to see 2 points as separated), generally measured in line pairs per mm (lp/mm) and inversely related with size of base unit
• axial spatial resolution
• angular or lateral space resolution
• contrast resolution (eye can recognize 16 different gray tonalities)
• signal-to-noise ratio (SNR / S/N) The ratio between the amplitude of the received signal and background noise, which tends to obscure that signal. SNR, and hence image quality, can be improved by such factors as increasing the number of excitations (NEX), increasing the field of view (FOV), increasing slice thickness, size of base unit, etc. SNR also depends on the electrical properties of the patient being studied and the type of receiving coil used.
• contrast-to-noise ratio (CNR)
• signal averaging : a SNR improvement method that is accomplished by taking the average of several FIDs made under similar conditions. This is also referred to as the number of excitations (NEX) or the number of acquisitions. The approximate amount of improvement in SNR is calculated as the square root of the NEX.
• number of signal averages (NSA)
• interventional radiology : the branch of radiology concerned with providing diagnosis and treatment of disease by a variety of percutaneous procedures performed under the guidance of radiologic imaging.

 
• Structural imaging
• landmark : a readily recognizable anatomical structure used as a point of reference in establishing the location of another structure or in determining certain measurements
• visible light (illumination)
• inspection
• constitution : the make-up or functional habit of the body, determined by the genetic, biochemical, and physiologic endowment of the individual, and modified in great measure by environmental factors
• normosplanchnic normotype
• megalosplanchnic brachytype (more exposed to hypervagotony)
• microsplanchnic longitype (more exposed to hypersympatheticotony, dyspepsia and parkinsonism)
• body or constitutional type : a constellation of traits related to body build.
• asthenic type : a constitutional type marked by a slender body, long neck, long, flat chest and abdomen, and poor muscular development.
• athletic type : a constitutional type marked by broad shoulders, deep chest, flat abdomen, thick neck, and good muscular development.
• pyknic type : a constitutional type marked by a rounded body, large chest, thick shoulders, broad head, and short neck.
• dysplastic type : any constitutional type that differs from the asthenic, the athletic, and the pyknic types.
• sympatheticotonic type : a type of physical constitution characterized by sympathicotonia.
• facies : the expression or appearance of the face
• composed (normal)
• facies abdominalis : the expression of the face characteristic of abdominal disease: it is pinched, anxious, and furrowed, with the nose and upper lip drawn up.
• facies hepatica : a thin face with sunken eyeballs, sallow complexion, and yellow conjunctivae, characteristic of certain chronic disorders of the liver.
• adenoid facies : the dull expression, with open mouth, sometimes seen in children with hypertrophy of the pharyngeal tonsils (“adenoids”).
• facies bovina / bovine or cow face : a term sometimes applied to the appearance of the face in craniofacial dysostosis
• facies hippocratica / hippocratic face : a drawn, pinched, and pale appearance of the face, indicative of approaching death (agony)
• hemolytic facies : increased erythropoietic activity to compensate for hemolysis leads to expansion of the marrow space. During childhood red marrow occupies almost the whole of the skeleton and there is hardly any space for expansion without encroaching on the cortex of the bones. This results in thinning of the inner and outer tables of the skull and increased space between them. The head appears large with frontal and parietal prominences. The eyes are widely spaced and nose bridge is flattened. The malar bones are prominent and increase markedly in size exceeding the growth in the soft tissues thereby exposing the upper teeth. Due to overgrowth of the upper jaw there is malocclusion of the teeth. All these features together give rise to characteristic hemolytic facies which are an evidence of hemolysis since early childhood.
• Hutchinson's facies : a peculiar appearance in ophthalmoplegia externa, the eyeballs being fixed, the eyebrows raised, and the lids drooping.
• leonine facies / facies leontina : a peculiar, deeply furrowed, lionlike appearance of the face, seen in certain cases of advanced lepromatous leprosy and in other diseases associated with facial edema such as coast erysipelas
• leontiasis : the leonine facies of lepromatous leprosy, due to nodular invasion of the subcutaneous tissue of the face, giving it a vaguely leonine appearance.
• Marshall Hall's facies : the facies of hydrocephalus: a triangular face with a broad forehead and prominent frontal bones.
• myasthenic facies : the characteristic facial expression in myasthenia gravis, caused by ptosis and weakness of the facial muscles.
• myopathic facies : the peculiar facial expression produced by relaxation of the facial muscles, as in Landouzy-Dejerine dystrophy.
• Parkinson's or parkinsonian facies : a stolid masklike expression of the face, with infrequent blinking, pathognomonic of parkinsonism
• Potter facies : the characteristic facial appearance seen with oligohydramnios sequence, consisting of a flattened nose, receding chin, wide interpupillary space, large, low-set ears, and less commonly other anomalies.
• dish or dished face / facies scaphoidea : a facial deformity characterized by a prominence of the forehead, a recession of the midface and lower half of the nose, a lengthening of the upper lip, and a prognathic chin
• frog face : flatness of the face due to intranasal disease.
• facies lunata / moon face / moon-shaped face : rounded face observed in Cushing's diseasedue to fat storing in Bichat boil
• cachectic facies during cachexia : deepened eyes, thinning of hypoderma => evidence of sternocleiomastoideal muscles and bone prominences.
• mixoedematous facies during hypothyroidism : vague look, increase of connectival tissues => false fat.
• asymmetrical facies : facial nerve palsy
• acromegalic facies in patients with acromegaly
• eyeballs
• eyelids
• mongoloid facies in patients with Down's syndrome
• diseases of skin
• fetor oris / fetor ex ore / halitosis / stomatodysodia : offensive breath; bad breath
• fetor hepaticus : the peculiar odor of the breath characteristic of hepatic disease; liver breath.
• (antalgic) position : a bodily posture or attitude assumed by the patient to achieve comfort in certain conditions
• decubitus position : the position of an individual lying on a horizontal surface, designated, according to the portion of the body resting on the surface
• dorsal decubitus or position / supine position : the posture of a person lying on his back
• left lateral decubitus : on the left side
• right lateral decubitus : on the right side
• ventral decubitus / prone position : patient lying on the abdomen face down
• passive positions
• active positions
• indifferent position
• obliged position
• orthotonos position / orthotonos / orthotonus : tetanic fixation of the head, body, and limbs in a rigid straight line.
• opisthotonos / opisthotonus position
• emprosthotonos / episthotonos  position
• orthopnea position : the patient assumes an upright or a semivertical position by using two or more pillows to support his head and chest from the recumbent position, or he sits upright in a chair. Used when the patient has difficulty in breathing except in the upright position (orthopnea).
• congestive heart failure
• raised with flexed arms : pancreatic colic
• stretched : vertebral fracture or disk herniation
• on the affected side : pleural effusion, spontaneous pneumothorax, gastric colic, biliary colic or renal colic
• on the healthy side : pleuritis or rib fracture
• seated : dyspnea
• gun cock position : meningitis
• scorbutic position : a pseudoparalytic position characteristic of advanced infantile scurvy, in which the infant lies quietly with the legs flexed at the knees and the hips flexed and externally rotated
• tripod position : a position assumed by the patient with abdominal weakness or meningeal irritation while sitting in bed, in which he supports himself with his hands in a plane posterior to his pelvis. A sitting position assumed by the patient with respiratory insufficiency, in which his hands are placed anterior to the frontal plane
• Mohameddan pray position : pericarditis
• sizes : visual comparison
• orchidometer : an instrument for measuring the testis.
• Prader orchidometer : a string of plastic models of testicular shape, marked according to their volume in cubic centimeters; used for measuring the size of the testes in genital development


• ophthalmoscopy / funduscopy / funduscopic examination / posterior segment examination : the examination of the interior of the eye (fundus oculi) with the ophthalmoscope (which has a lens system to eliminate the refractive errors in  both examiner and patient)
• medical ophthalmoscopy : ophthalmoscopy performed to diagnose local or systemic diseases such as aneurysms in retinal artery in systemic arterial hypertension or diabetes mellitus, and cerebral tumor.
• direct ophthalmoscopy : direct, close-range ophthalmoscopic observation of the fundus; the image is virtual, erect, and magnified.
• direct ophthalmoscope : a hand-held instrument with a light-and-mirror system that affords an upright, or unreversed, monocular view of a narrow field of the fundus of approximately 15 times magnification. The right eye of the examimer is used to look at the patient's right eye by placing the left hand on the patient's forehead to avoid excessive vicinity to the eyeball, and viceversa
• indirect ophthalmoscopy : ophthalmoscopic examination of the fundus with the interposition of a strong convex lens between the observer and the patient; the image is real and inverted.
• indirect ophthalmoscope : one that produces an inverted, or reversed, direct image of 2 to 5 times magnification, depending on the dioptic power to the examining lens, less magnified but wider view of the fundus than does the direct ophthalmoscope.
• metric ophthalmoscopy : that performed for the measurement of refraction
• scanning laser ophthalmoscopy
• contact lenses with mirrors can be used to look at very peripheral retinal areas. Orbitary infiltrations of anaesthetic can cause hematomas.
• binocular ophthalmoscope / stereo-ophthalmoscope : an ophthalmoscope by which the fundus of the eye is viewed with both eyes through 2 eyepieces
• ophthalmospectroscopy : ophthalmoscopic and spectroscopic examination of the ocular fundus
• binophthalmoscope : an ophthalmoscope for examining both fundi of the patient at one time
• endoscopy : visual inspection of any cavity of the body by means of an endoscope (an instrument for examination of the interior of a cavity or hollow viscus
• rigid (before introduction of fiberoptics (the transmission of an image along flexible bundles of coated parallel glass or plastic fibers that propagate light by internal reflections), light could spread just straightly)
• flexible
• fiberscope : a flexible fiberoptic endoscope)
..., which can be introduced into ...
• natural passages
• nasopharyngeal mirror
• nasopharyngoscope
• laryngoscopy : examination of the interior of the larynx
• direct laryngoscopy : direct visual examination of the interior of the larynx performed with a speculum or with a fiberoptic laryngoscope.
• suspension laryngoscopy : examination of the larynx performed with a direct laryngoscope suspended so as to leave both hands of the examiner free.
Macintosh laryngoscope blade (1943) was specifically designed for indirect lifting of the epiglottis. Macintosh lighted stylet (1957) was made to project beyond the tacheal tube, providing additionally illumination during conventional direct laryngoscopy.

Magill laryngoscope blade :

• mirror or indirect laryngoscopy : examination of the interior of the larynx by observation of the reflection of it in a laryngeal mirror.
• microlaryngoscopy : examination of the interior of the larynx with a laryngoscope with binocular magnificaton.
• rigid laryngoscope : modifications of the traditional blades are primarily designed to overcome certain difficult airway problems, such as limited mouth opening, "anterior larynx", sternal space restriction, small intra-oral cavity and immobile or unstable cervical spines.
• Flexibater™ Adjustable Laryngoscope (Arco Medic Ltd., Omar, Israel) is similar in shape to a MacIntosh laryngoscope but the distal tip changes its shape according to the pressure that is placed on the trigger
• flexible tip or levering laryngoscopes, such as CLM laryngoscopes (Mercury Medical, Clearwater, FL), the Flipper (Rusch Inc., Deluth, GA) and Heine Flex Tip (Heine Optotechnik, Herrsching, Germany) are MAC laryngoscope blades designed with a hinged tip controlled by a lever at the proximal end and are extremely useful in patients with a recessed mandible and decreased mouth opening. A lever controls the tip angle through 70° during intubation to lift the epiglottis if necessary in order to improve laryngeal visualization.
• straight laryngoscopes continue to be modified in design adn there has been a resurgence of interest in their routine use for tracheal intubation. The Henderson laryngoscope blades (Karl Stortz Gmb & Co., KG, Tuttlingen, Germany) have an improved tip and light, as well as a larger cross-sectional area. When used with the paraglossal technique, a better view is obtained, yet at the expense of less space in which to manipulate an ET
• X-Lite Video Set™ (Rusch Inc., Duluth, GA) includes MAC laryngoscope blades, handle with integrated vdeo camera and control unit with LCD screen, and xenon light source. The wide angle camera allows excellent visualization and video documentation of laryngoscopy and intubation. Extreme positioning of the head is unnecessary
• indirect rigid fiberoptic laryngoscopes were designed to facilitate tracheal intubation in the same patient population as those comsidered for flexible fiberoptic bronchoscopy, such as limited mouth opening or neck movement. Compared to the flexible FOBs, they are more rugged in design, control soft tissue better, allow for better management of secretions, are mroe portable (with the exception of the new portable FOBs) and are not as costly. Intubation can be performed via the nasal or oral route and can be accomplished in awake or anesthetized patients
• Bullard™ Elite Laryngoscope (Circon, ACMI, Stamford, CT) is the most recent version of the Bullard laryngoscope and is the only indirect fiberoptic laryngoscope which incorporates attachable metal stylets for use and can be used with a conventional laryngoscope handle. It also has a working channel for oxygen insufflation, dsuction, and instillation of local anesthetics. It is available in both adult and pediatric sizes (newborn/infant and child). 6 methods of intubation have been described
• UpsherScope™ (Mercury Medical, Clearwater, FL) is the simplest in design in this category. Unlike the Bullard, there are no detachable stylets or extra ports, but rather a C-shaped delivery slot along the right side of the instrument. Although only an adult size is currently available, a pediatric version is under development
• WuScope™ (Pentax Precision Instrument Corp., Orangeburg, NY) is conceptually similar to both the Bullard laryngosocpe and UpsherScope. It has a handle, an anatomically designed blade, a a fiberoptic view port, and a port for oxygen insufflation. The blade portion has 23 detachable stainless steel ports, which require assembly. The fiberoptic mechanism consists of a fiberoptic rhinolaryngoscope Achi LA-SI. This feature accounts for its better visualization capacity and higher cost than the aforementioned 2 scopes.
• laryngotracheoscopy : peroral laryngoscopy and tracheoscopy.
• laryngotracheobronchoscopy : endoscopic examination of the larynx, trachea, and bronchi.
• tracheoscopy : the inspection of the interior of the trachea.
• tracheobronchoscopy : inspection of the interior of the trachea and bronchi^ref
• fiberoptic bronchoscopy (FOB)
Indications :
• evaluation of bronchial mucosa
• removal of thick mucus plugs
• biopsy of endobronchial neoplasia
• removal  of foreign bodies (the most common indication in babies)
Contraindications : unstable cardiovascular status and cardiac arrhythmias
Bronchoscopes used in pediatric patients :

	scope designation	outer diameter [mm]	working length [cm]	suction channel [mm]	smallest endotracheal tube size (tube sizes are the smallest possible with each instrument. Utilizing these bronchoscopes with these sizes often leads to limited ability to ventilate, and the distinct possibility of the scope meeting significant frictional resistance as it is passed through the tube. It will always be safer and preferable to use 0.5 size larger than those listed or a laryngeal mask of larger caliber, especially in patients with significant intrinsic lung disease)
Olympus pediatric fiberoptic and video bronchoscopes	BF-N20	2.2	55	none	30
	BF-XP40	2.8	60	1.2	35
	BF-3C40	3.6	60	1.2	45
	BF-3C160 (video)	3.8	60	1.2	5.0
Pentax pediatric fiberoptic bronchoscope (Pentax; Asahi Optical; Tokyo, Japan)	FB-7P	2.4	60	none	3.0-3.5
	FB-10V	3.4	60	1.2	4.5

Web resources : Bronchoscopy and Lung Tumors
• gastrointestinal endoscopy
• peroral endoscopy : examination of organs accessible to observation through an endoscope passed through the mouth
• esophagoscopy : endoscopic examination of the esophagus by means of an esophagoscope (a flexible or rigid instrument for inspecting the lumen of the esophagus and carrying out diagnostic and therapeutic maneuvers such as taking biopsy specimens and removing foreign bodies)
• fiber optic esophagogastroscopy : endoscopic examination of the esophagus and the stomach by mneans of a fibergastroscope
• fiber optic esophagogastroduodenoscopy (EGD / EGDS) : endoscopic examination of the esophagus, stomach, and duodenum.

Web resources : The adventures of GastroMan
• gastrocamera : a small camera that can be swallowed or passed down the esophagus on an appropriate instrument to photograph the inside of the stomach; it is attached to an external control box by a hollow flexible tube, and fitted with a flash lamp and inflation bulb. After the camera is inserted into the stomach, the bulb is inflated and pictures are taken as the flash lamp is triggered.
• fiber optic push enteroscopy
• anuscopy (anuscope)
• proctoscopy / rectoscopy : inspection of the rectum with a proctoscope
• rectosigmoidoscopy / rectoromanoscopy / proctosigmoidoscopy : examination of the rectum and sigmoid with the sigmoidoscope
• fiber optic (rectosigmoido)colonoscopy / coloscopy : examination by means of the colonoscope / fibercoloscope
• fiber optic left (rectosigmoido)colonoscopy :
• fiber optic left and transverse (rectosigmoido)colonoscopy
• fiber optic (rectosigmoido)pancolonoscopy / proctocolonoscopy : the inspection of the interior of the rectum and lower portion of the colon.
16% of morning colonoscopies and 22% of afternoon colonoscopies involve inadequate bowel preparation (P = .0005). Except for poor bowel preparation precluding completion, patients in both groups had similar risk factors predictive of incomplete colonoscopy. Total incompletion rates reached 8.1% in the afternoon versus 4.4% in the morning (P = .0003). After excluding incomplete colonoscopies due to poor bowel preparation and colonic pathology precluding completion, incompletion rate was still higher in the afternoon procedures (4.3% vs 2.8%). The majority of our patients receive [polyethylene glycol] electrolyte-based bowel preparation in the evening prior to the day of the scheduled colonoscopy. A shift of scheduling from afternoon to morning only could result in significant avoidance of inadequate results and, therefore, repeat procedures
• wireless video capsule endoscopy (WCE) allows imaging of the entire small intestine and appears to provide the most complete, noninvasive endoscopic perspective of the entire small intestinal mucosa. This new endoscopy system has been shown to have an excellent diagnostic ability for small bowel disease, bleeding and chronic abdominal pain^{ref1, ref2, ref3, ref4, ref5, ref6, ref7, ref8, ref9}. Small bowel imaging is important in the evaluation of obscure gastrointestinal bleeding^ref, inflammatory disease of the small bowel^ref and tumors. The main methods of small bowel imaging have been either push enteroscopy or small bowel barium studies for evaluating the luminal pathology. Angiography is a diagnostic option in the context of suspected small intestinal bleeding. Therefore, wireless capsule endoscopy has been applied for many kinds of small bowel diseases^{ref1, ref2, ref3, ref4, ref5, ref6, ref7, ref8, ref9}.
• Given M2A™ / PillCam™ (source : Given Imaging (Yoqneam, Israel)^ref) WCE was developed in the late 1990s^ref and consists of :
• the small size (26 mm long and 11 mm in diameter, weighing about 4 g) swallowable single-use capsule contains a miniature color video camera, 4 light sources, 2 silver oxide batteries and a radiotransmitter that using UHF signals transmits images from the capsule to the Data Recorder. The capsule glides naturally through the digestive tract and is naturally excreted 3 vital technologies that made the tiny imaging system possible are improvement of the signal-to-noise ratio (SNR) in complementary metal oxide semiconductor (CMOS) detectors (they have active pixel resolutions that provide comparable performance to charge coupled device CCDs, while drawing less power than CCDs), development of white light emitting diodes (LEDs), and development of application-specific integrated circuits (ASICs).


• Given DataRecorder, worn on a belt around the waist that receives signals transmitted by the capsule through an array of sensors placed on the patient's body. While wearing the belt, patients are free to continue their daily activities during the GI examination. During a typical 8-hour test, the M2A capsule transmits approximately 50,000 images to the portable data recorder.
• the RAPID™ Workstation, equipped with Given Imaging's proprietary RAPID (Reporting and Processing of Images and Data) Application Software that  processes the data downloaded from the Data Recorder into a short video film clip and presents other relevant GI parameters : it is a modified personal computer which has been designed for storage, the processing and presentation of captured images and the generation of reports^{ref1, ref2, ref3, ref4, ref5, ref6, ref7, ref8, ref9}. A suspected blood indicator (SBI) detects blood and marks appropriate images for interrogation. Recent advances enable the physician to localize images, detect suspected locations of bleeding, and more efficiently view and archive the RAPID videos.
Indications : patients with ...
• occult gastrointestinal bleeding (OGIB)
• chronic diarrhea
• unknown abdominal pain
• Crohn disease (CD)
• iron-deficiency anemia
• abdominal discomfort in NSAID takers
• staging of gastrointestinal tumors
... in which previously performed gastroscopy, colonoscopy, and small-bowel follow-through were not conclusive.
Preparation : bowel preparation with simethicone results in significantly better visibility of small bowel mucosa because of fewer intraluminal bubbles^ref
Advantages :
• because the capsule passes through the gastrointestinal tract naturally, there is no air insufflation, sedation, or scope trauma involved, which may alter diagnostic yield
• better tolerated than push enteroscopy
• safe in patients with cardiac pacemakers. Pacemakers do not interfere with capsule imaging^ref
• M2A™ Capsule is disposable, so patients are not required to return the device to the physician. It is NOT absorbed in the body!
Disadvantages :
• relies on an intact swallowing mechanism and unimpeded passage of the capsule through the pylorus. A technique has been described for endoscopic delivery of the capsule in the duodenum in patients with oropharyngeal dysphagia, anatomical abnormality (pyloric stenosis, prior gastric surgery), or gastroparesis^ref
• some patients experience symptomatic obstruction
• failed excretion of one of the capsules because of an unknown ulcerated intestinal stricture
• localization of findings within certain regions of the small bowel may be difficult : updated localization software programs are available to assist with these challenges
• impossibility of taking biopsies and therapeutic interventions
Contraindications : Billroth I gastrectomy
Web resources :
• Atlas of gastrointestinal endoscopy by Atlanta South Gastroenterology, P.C.
• Atlas of gastrointestinal endoscopy by A.Freytag and T.Diest
• American Society for Gastrointestinal Endoscopy (ASGE)
• urethroscopy : visual inspection of the interior of the urethra.
• (urethro)cystoscopy : direct visual examination of the urinary tract with a cystoscope
• (urethrocysto)ureteropyeloscopy / ureteroscopy : examination of the ureter by means of a fiberoptic endoscope (ureteroscope).

Complications : ureteral avulsion. Therapy : renal autotransplantation for the ureter reconstruction
• ureterorenoscopy : visual inspection of the interior of the ureter and kidney by means of a fiberoptic endoscope (ureterorenoscope) for such purposes as biopsy, removal or crushing of stones, etc.
• colposcopy : examination of the cervix and vagina by means of the colposcope (an instrument with a magnifying lens). It requires 20-30' : no gynaecological visits, topical vaginal therapies or sexual intercourses in 3-4 days before colposcopy; best in ovulatory stage when the cervical mucus is clearest) : after detersion with 3% acetic acid, the observer can detect punctate (erythroplakia) or mosaic (capillary network) look (which can anyway be representative of simple cervicitis) for cervical SCC and just barrel deformation of cervix for cervical adenocarcinoma. Careful examination of squamocolumnar junction, where 90% of malignant lesions are located.


• colpomicroscopy : examination of tissues of the cervix in situ with the colpomicroscope (an instrument with higher powers of magnification than the colposcope)
• culdoscopy : visual examination of the female pelvic viscera by means of an endoscope (culdoscope) introduced into the pelvic cavity through the posterior vaginal fornix.
• vaginoscopy : inspection of the vagina
• amnioscopy : direct observation of the fetus and the color and amount of the amniotic fluid by means of a specially designed endoscope inserted through the uterine cervix
• speculum : an instrument that exposes the interior of a passage or cavity of the body by enlarging the opening.


• Bozeman's speculum : a bivalve speculum the blades of which remain parallel when separated.
• nasal speculum (fig. A)
• rectal specula (fig. B)
• Brinkerhoff's speculum : a rectal speculum consisting of a conical tube having a closed extremity, but provided with a sliding bar on the side which provides an opening.
• Cook's speculum : a 3-pronged rectal speculum.
• sphincteroscope : a speculum for inspecting the anal sphincter.
• Kelly's speculum or sphincteroscope : a rectal speculum tubular in shape and fitted with an obturator
• Martin and Davy speculum : a rectal speculum consisting of a conical cylinder with an obturator.
• Mathews' speculum : a 4-pronged rectal speculum.
• speculum for otoscope (fig. C)
• vaginal specula
• duck-billed speculum (fig. D) : a form of 2-valved vaginal speculum.
• Sims' speculum : a double duck-billed vaginal speculum.
• Fergusson's speculum : a cylindrical vaginal speculum made of silvered glass.
• Graves' speculum : a type of 2-valved vaginal speculum.
• eye speculum (fig. E) : an appliance for keeping the eyelids apart.
• stop speculum : an eye speculum with an appliance for controlling the degree to which its branches spread.
• artificial passages created by surgical cuts
• mediastinotomy => thoracoscopy / pleuroscopy : the diagnostic examination of the pleural cavity through an endoscope.
• mediastinotomy => mediastinoscopy : examination of the mediastinum (e.g. for lymph node biopsy) by means of an endoscope inserted transcutaneously through an anterior incision in the suprasternal (jugular) notch, permitting direct inspection and biopsy of tissue in the anterior superior mediastinum.
• cholecystotomy => fiber optic cholecystoscopy :
• laparotomy => laparoscopy / abdominoscopy / celioscopy / peritoneoscopy (examination of the interior of the abdomen) was introduced by Fevers in 1933. Local anaesthesia (general in babies). Injection of 2-8 L of previously heated gas (air, CO₂ (not flammable and easily absorbed preventing gaseous embolism), Ar or N₂O) through Veress needle (inserted blindly or after small incision of muscular fasciae with Hasson trocar) creates a pneumoperitoneum (intraabdominal pressure = 10-15 mmHg) into which the laparoscope can be moved without risk of injuring organs. 5-10 mm cannulas with antireflux valves are inserted through 0.5 cm-wide incisions, then 10-mm CCD cameras (0°-30°-45°-90° : the greatest the angle, the higher the light intensity required), 2-10 mm cold light optics, trocars, mechanical suturers (15-33 mm), and other disposable or sterilizable devices (25-35 mm in length : dissectors, divaricators) are inserted into cannulas : they don't hurt muscles and the blade is retracted immediately after peritoneum cut. The device also presents a light source, an optic fibre camera, needles, endo-loops, endo-knots, electrobistoury and cautery. The distance between surgeon and monitor should be 3 times the transverse diameter of the monitor and the latter should be placed lower than surgeon's eyes. 2 monitors are placed at both sides of the patient to allow vision to both the surgeons and his collaborators. Threads are shorter (7 cm) and laces longer (20 cm) than in open surgery to allow easier maneuvers : endoski needles are used



• videolaparoscopy : laparoscopic surgery aided by a video camera
• laparogastroscopy : examination of the interior of the stomach through an abdominal incision
• transcolonic endoscopy : examination of the lumen of the colon by means of an endoscope inserted through an incision in its wall.
• laser laparoscopy : introduction of a laser beam into the abdomen through a laparoscope, done to vaporize tissue, as in treating endometriosis or to lyse adhesions
• pelvioscopy : the inspection or visual examination of the pelvis or pelvic viscera, as with a laparoscope or pelviscope
• videolaseroscopy : a modification of laser laparoscopy in which the inside of the cavity is visualized through a video camera that projects an enlarged image onto a video monitor.
Side effects from pneumoperitoneum :
• compression of peripheral and splanchnic circulation => reduction of venous blood return to heart => sympathetic reflex => compensatory tachycardia (facilitated by the hypercapnia caused by CO₂ insufflation) and peripheral vasoconstriction => further reduced blood return and hypercapnia; reduced EF
• cardiac arrhythmias (25-45%), usually sinusal bradycardia due to vagal stimulation (severe in 30%)
• intraabdominal pressure > 12 mmHg may cause
• a reduction in femoral vein blood flow up to 40% due to anti-Trendelenburg position => increased risk of deep vein thrombosis (DVT), only partially compensated by earlier patient mobilization, reduced surgical stress => prophylaxis with LMWH
• rarely organ failure
• respiratory apparatus : reduced lung volume, hypercapnia, reduced pulmonary compliance, increased airway resistance, reduced vital capacity, anti-Trendelenburg position
• gaseous embolism after injury of intraabdominal blood vessels with Veress needle or other devices. Lethal dose for CO₂ = 25 ml/kg; for air (5 ml/kg)
• hypothermia : expanded CO₂ cools the abdomen up to -0.3°C every 50 l of insufflated gas. Previous heating is recommended
Positive effects :
• reduced stress => reduced postoperatory infections
• reduction of pain, hypermetabolic status, and neuroendocrine response => reduced cardiac complications (0.06% vs. 1.4%) and restrictive pulmonary syndrome
• faster recovery of intestinal peristalsis
Variants :
• gasless laparoscopy : lifting of abdominal wall via mechanical retractors (e.g. Laparolift^®, Origin MedSystem Inc., USA) hooking the peritoneum or the subcutis, fixed to the operatory table. After conventional laparoscopic cholecystectomy (with conventional pressure pneumoperitoneum (CPP), ie. IAP = 12-15 mmHg), postoperative nausea and vomiting (PONV) have been reported in up to 68% of patients. After laparoscopic cholecystectomy with combined low-pressure pneumoperitoneum and abdominal wall lift, the incidence of PONV was 8%. In addition, postoperative drowsiness was also of significatively longer duration and right shoulder pain occurred more often after conventional carbon dioxide pneumoperitoneum. Also, the more carbon dioxide used the more restless were patients in the recovery room. Disadvantages : tent effect, unproper trocar placement
• hydropneumatic abdominal wall suspension

Web resources :
• Laparoscopy.com
• WebSurg : laparoscopic surgery
• Laparoscopy Hospital, India
• Laparoscopic Surgery including cholecystectomy, hernia repairs, colon, gastric, hiatal hernia, appendectomy.
• Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
• Gastrointestinal Endoscopy
• Belgian Group for Endoscopic Surgery (BGES)
• Fundamentals of Laparoscopic Surgery
• University of Massachusetts EndoSurgery Center : minimally invasive and hand assisted laparoscopic surgery.
• Duke US Surgical Endosurgery Center
• Plastic surgery performed using endoscopes
• Journals : Surgical laparoscopy, endoscopy and percutaneous techniques
• retroperitoneoscopy : surgeon stands on dorsal side of patient; finger dissection of retroperitoneal space via an incision in the lumbar trigone (port I) and inflated balloons. Placement of trocars under palpatory control guided by the index finger. Exposure of retroperitoneal organs by incision of renal fascia^ref




• arthrotomy => arthroscopy : examination of the interior of a joint with an arthroscope

Web resources :
• Knee Arthroscopy
• MicroSpine : minimally Invasive Spinal Surgery specialists
• Arthroscopy of the Foot and Ankle
• Arthroscopy - an overview by the American Academy of Orthopaedic Surgeons.
• San Diego Shoulder Arthroscopy
• Endius : minimally invasive endoscopic spine surgery systems. Mission is to provide less traumatic and more effective surgery for patients treated for back pain.
• Neurosurgeon and Pain Management Specialist
• Carpal Tunnel Syndrome
• Shoulder Surgeries and Injuries
• Temporomandibular joint (TMJ) disorders and arthroscopy
• ventriculoscopy : direct examination of the cerebral ventricles by means of an endoscope or cystoscope.
Advantages over radiological investigations :
• detection of flat lesions thanks to
• color
• shape and fragility of superficial blood vessels
• biopsy
• diaphanoscopy / transillumination : the passage of light through body tissues for the purpose of examination, the object or part under examination being interposed between the observer and the light source
• paranasal sinuses transillumination
• thyroid transillumination
• retroillumination : to illuminate from behind by reflecting light from a deeper structure
• palpation : the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the consistency of the parts beneath in physical diagnosis.
• bimanual palpation : examination with both hands.
• light touch palpation : light palpation of the surface of the abdomen and thorax with the fingertips for the purpose of finding the outlines of the organs.
• psauoscopy : a method of physical examination done by passing the ball of the index finger back and forth lightly over the margin of an abnormal area. Over the pathological area the finger seems to encounter greater resistance and the skin seems more tense and less supple.
• neck
• anterior triangles (mandible, sternocleidomastoideal muscle) : thyroid, anterior cervical lymph nodes, carotid artery, internal jugular vein.
• posterior triangles (sternocleiodmastoideal and trapezius muscles) : posterior cervical lymph nodes
• neck stiffness => meningism
• superficial lymph nodes
• fremitus : a vibration perceptible on palpation
• subjective fremitus : one felt by the patient on humming with the mouth closed.
• tactile fremitus : a strong vocal fremitus that can be felt by a hand on the thorax.
• pericardial fremitus : a thrill of the chest wall due to the friction of the surfaces of the pericardium over each other.
• pleural fremitus : a palpable vibration of the wall of the thorax due to a friction rub between the opposing surfaces of the pleura.
• bronchial or rhonchal fremitus : palpable vibrations produced by the passage of air through a large bronchial tube filled with mucus
• pectoral or vocal fremitus (VF) : a thrill caused by speaking, perceived by the ear of the auscultator applied to the chest
• reduced in :
• pneumothorax
• pleural effusion
• bronchial obstruction
• emphysema
• tussive fremitus : one felt on the chest when the patient coughs.
• epigastric pulsation is due to right ventricular hypetrophy or abdominal aortic aneurysm
• percussion : the act of striking a part with short, sharp blows as an aid in diagnosing the condition of the underlying parts by the sound obtained.
• succussion : shaking of the body during an examination; a splashing sound is indicative of the presence of fluid and air in a body cavity.
• hippocratic succussion : succussion to elicit a splashing sound in the chest
• auscultatory percussion : auscultation, usually by stethoscope, of the sound produced by percussion.
• bimanual percussion : the usual manner of percussion in which the middle finger of the left hand is placed against the body wall and is struck a quick blow with the end of the bent right middle finger.
• comparative percussion : percussion of two or more areas in order to compare the sounds obtained.
• deep percussion : percussion in which a firm blow is struck in order to obtain a note from a deep-seated tissue.
• Lerch's drop stroke percussion : instrumental percussion in which the plexor is allowed to fall by its own weight on to the pleximeter, the elements considered in the examination being the sound heard, the vibrations felt in the handle of the plexor, and the rebound of the plexor seen
• finger percussion : that in which the fingers of one hand are used as a plexor, and those of the other as a pleximeter.
• fist percussion : percussion in which the fist is brought down with a moderate thump over the area to be tested.
• immediate percussion : that in which no pleximeter is used.
• instrumental percussion : that in which a plexor or hammer is used.
• mediate or pleximetric percussion : that in which a pleximeter is employed.
• palpatory percussion : a combination of palpation and percussion, affording tactile rather than auditory impressions.
• Murphy's piano percussion : percussion by striking the body by the 4 fingers one after the other, beginning with the little finger
• slapping percussion : percussion made by a slapping blow: used in comparing the resonance.
• strip percussion : percussion which starts from above and progresses downward, thus covering a “strip” of the chest wall.
• tangential percussion : percussion with the pleximeter placed vertically on the body, the strokes being applied to the pleximeter in a direction parallel with the surface of the skin.
• orthopercussion : percussion in which the distal phalanx of the pleximeter finger is held perpendicularly to the chest wall.
• Goldscheider's threshold percussion : percussion performed by tapping lightly with the finger upon a glass rod pleximeter, one end of which, fitted with a rubber cap, rests upon an intercostal space, the rod being held at an angle to the surface of the thorax and parallel to the borders of the organ to be delimited. This method confines the percussion vibrations to a very restricted area
• resonance : the prolongation and intensification of sound produced by transmission of its vibrations to a cavity, especially a sound elicited by percussion
• amphoric murmur or resonance : a sound heard upon percussion or auscultation, resembling that produced by blowing over the mouth of an empty bottle, as in amphoric respiration
• osteal resonance : the sound elicited by percussion over a bony structure.
• tympanitic resonance : the drumlike reverberation of a cavity full of air
• dullness : diminished resonance on percussion; also a peculiar percussion sound which lacks the normal resonance.
• tympanitic dullness : resonance of a dull and diminished quality.
• flatness : a peculiar sound lacking resonance, heard on percussing a part that is abnormally solid
• topographic percussion : the demarcation and outlining of a dull area by percussion to determine the boundaries of organs or parts of organs.
• chest percussion
• respiratory percussion : percussion during respiration so as to bring out the difference in the percussion notes of inspiration and expiration.
• clear sound at lung level
• relative flatness at diaphragm level
• absolute flatness at liver level (clear sound if subfrenic aereal "sick" during pneumoperitoneum !)
• tympanitic dullness at bowel level
• paradoxical percussion : resonance of the chest combined with abundant rales as in acute edema of the lungs.
• bell tympany : a modified tympanitic note heard on percussion of the chest in some cases of pneumothorax.
• Plesch's pencil percussion : percussion within the intercostal spaces to avoid setting the ribs into vibration, the pleximeter finger with the first interphalangeal joint flexed at a right angle.
• over cardiac area :
• relative obtuseness : with interposition of left lung
• absolute obtuseness : without interposition of left lung
• box-note : a hollow percussion sound heard in the chest of a person with emphysema.
• bandbox resonance or sound : the extremely resonant sound elicited by percussion in cases of emphysema of the lungs
• cracked-pot resonance or sound / bruit de pot fêlé : a peculiar sound elicited by percussion over a pulmonary cavity that communicates with a bronchus
• hydatid resonance : a peculiar sound heard in the combined auscultation and percussion of a hydatid cyst.
• skodaic resonance or tympany / Skoda's sign or tympany : increased percussion resonance at the upper part of the chest, with flatness below it; heard above a large pleural effusion or area of consolidation
• Gerhardt's dullness or triangle : a triangular area of dullness to percussion above the third left rib, an inconstant sign in patent ductus arteriosus
• abdominal percussion
• Conradi's line : a line from the base of the xiphoid process to the point on the chest at which the apex beat is felt, indicating the upper limit of percussion dullness of the left lobe of the liver.
• tympanic or tympanitic resonance : the peculiar sound elicited by percussing a tympanitic abdomen
• shifting dullness : dullness on abdominal percussion, the level of which shifts as the patient is rolled from side to side; indicative of free fluid in the abdominal cavity.
• T-rays, or Terahertz radiation, are capable of showing high-resolution pictures of skin cancers that reveal exactly how far the disease has spread far more effectively than other imaging techniques. Unlike X-ray and magnetic resonance scans, the T-rays are only capable of penetrating a few millimetres of tissue and do not carry the same health risks. T-rays are able to detect slight differences in the water content of a tissue : cancer cells contain more water than those around them and show up brightly in scans. T-ray technology will be crucial in detecting the 85% of all cancers that are not visible with conventional scanning techniques
• X-rays => radiography

X rays are generated when electrons (or other charged particles) undergo severe acceleration (or deceleration). This can happen adventitiously in any electronic device that operates at several kV or more (e.g. electron microscopes) but it is a design feature of synchrotron and rotating anode vacuum tube X-ray generators.
• synchrotron radiation : here bunches of very high energy electrons (several GeV) move in a closed loop. At each bending point an intense and very narrowly defined pencil beam of radiation is emitted. The beam contains radiation of a wide range of energies - UV through to  X rays. Synchrotrons ( e.g. Daresbury laboratory near Warrington,  ESRF in Grenoble) are very large central facilities that have their own operating procedures and safety systems that visitors and users must follow.


• rotating anode tubes : laboratory scale sources of X-rays draw a beam of electrons from the cathode of a vacuum tube. The beam is accelerated through several kV and focussed on to an anode. The anode is usually rotating to provide for  efficient distribution and dissipation of heat. The X-rays produced at the impact point are distributed over a wide angular range and cover a wide range of energies up to a maximum energy determined by the voltage at which the tube is operated.


Most of the X-ray output of rotating anode sources has a continuous energy range that extends up to a value, E_max that, measured in electron volts (eV), is equal to the acceleration voltage applied to the tube.
(1 eV = 1.6 10^-19 Joules). This Bremsstrahlung (German for "braking radiation") arises from the accelerations suffered by the electrons during collision with the atoms of the anode. Superimposed on the Bremsstrahlung background there are intense narrow line emissions that are characteristic of the material of the anode. These characteristic lines are important for crystallography (for X-ray diffraction experiments and, particularly, for X-ray fluorescence analysis) but since they amount to only a few percent of the total X-ray output they are of little radiological importance.

Unlike radioactive sources, X-rays present no contamination hazard and X-ray generators can be made perfectly safe by being switched off. However X-ray generators can deliver dose rates greatly in excess of those available from laboratory radioactive sources. In the primary beam of an X-ray generator, the dose rate, D, at a distance, d,  from the anode depends on the beam current, I, the acceleration voltage, V, and the atomic number of the anode material, Z, (commonly, copper, Z=29, or tungsten, Z=74) approximately as D = C Z I V / d² , where C is a constant of proportionality.
Typical operating conditions (V = 50 kV; I = 10 mA) with a tungsten anode correspond to dose rates in the primary beam of
• @ d = 1m, D ~ 1 Sv/min
• @ d = 10 cm, D ~ 100 Sv/min
A dose of 3 Sv (enough to give radiation burns) would therefore be received in times of
• @ d = 1m,  ~ 3 min
• @ d = 10 cm, ~ 2 sec
For crystallographic purposes it is common practice to isolate one characteristic line of the X-ray spectrum either crudely by use of a Ni filter or more precisely by use of a monochromator crystal. This could reduce the dose rate by a factor of ~ 100 but even so a high degree of shielding is still essential to give acceptably low dose rates in the working environment  Attenuation factors > 10⁸ are needed to reduce the dose rate to the mSv/hr level. Fortunately this degree of shielding is easily achieved for X-rays.
Like g-rays, X-rays have no definite range - the intensity of radiation transmitted through a material falls exponentially with the thickness of the material. I = I₀ e^-mx, where m is the linear attenuation coefficient of the material
For typical 50 KeV X-rays the half value thicknesses, H_1/2 = 0.69/m, for some common materials are
• air : H_1/2 ~ 10m
• body tissue : H_1/2 ~ 3 cm
• lead (Pb) : H_1/2 ~ 0.1 mm
• steel : H_1/2   ~ 0.5 mm
An attenuation of I/I₀ = 10^-10 is achieved by lead of thickness 3.3 mm or by steel of thickness 16.6 mm.
Joints (e.g. between generator, collimator and camera or at the edges of any outer shields) must prevent leakage of radiation. Leakage dose rates must be kept below 7.5 mSv/hr to avoid the need for establishing controlled areas but, since X-ray shielding is easy to apply, the ALARA principle demands more than this. Extra shielding must be applied wherever a leak can be detected above the background level (1 mSv/hr should be detectable)
Radiation monitors in general laboratory use are usually Geiger counters or scintillation counters. Some are merely radiation detectors giving a reading in counts/sec that depends very much on the energy of the incident X-rays. Some are energy compensated to serve as dose rate meters, giving readings in mSv/hr  that are accurate to +/- 10% over a range of energies. Soft X-rays (< 25 KeV) do not easily penetrate the walls of detector probes , so probes with Be end windows may sometimes be required
Monitoring of the working environment using a dose rate meter must be done regularly and the results recorded. A suitable instrument for monitoring the primary beam radiation of generators operating at > 45 keV is the mini monitor 900 D. For dose rate measurements of monochromated radiations an instrument having a lower energy response will be needed.
Leak testing of joints can be done with a simple radiation detector provided that it is sensitive enough at the energies involved. Even at X-ray energies as low as 10 KeV the mini-monitor 900 X for example shows a count rate of 1 c/s (about twice the background rate) for a dose rate of 1 mSv/hr.
• target-skin or source-skin distance (SSD) : the distance from the focal spot on the target of the x-ray tube to the skin of the subject, as measured along the central ray.
Personal monitoring
• film badges (issued monthly) or thermoluminescent detectors (TLD's) ( issued quarterly) can detect doses > 0.05 mSv (~ 1/40 annual background)
• wear at chest height with serial number facing outwards
• not likely to detect accidental exposure to collimated beams but will indicate the level of diffuse scattered radiation
Relative radioopacity_x = opacity_x / opacity_H2O [Haunsfeld unit (HU)]
• metal => white
• bones (+1,000 HU) => clear gray
• coagulated blood (before hemolysis)
• coagulated blood (after hemolysis)
• liver (+80)
• blood
• muscle
• spleen
• pancreas
• gray matter
• white matter
• kidney
• adrenal glands
• mucus
• serum
• water (0)
• CSF and other fluids
• fatty tissue (-95 HU)  => dark gray
• lung
• air (-1,000 HU) => black
Usually the range of human tissues is -100 < x < +100 HU.
In diagnostic radiology, the most important attenuation coefficients for electromagnetic radiation are :
• linear attenuation coefficient (m) represents the loss of intensity per centimetre travelled distance and depends on the photon energy and the chemical composition and physical density of the material. The probability that an X-ray or g-ray photon will interact with the material it is traversing per unit path length traveled. It is usually reported in units of cm^-1. For monoenergetic X-rays, the fraction of incident X-rays expected to penetrate through a thickness x without interacting with the material is exp_-mx. The linear attenuation coefficient is equal to the mass attenuation coefficient (m/r) multiplied by the density r. The advantage of expressing the linear attenuation coefficient in this way is that the mass attenuation coefficient is independent of density and can be computed from the mass attenuation coefficients of the constituent elements. For any material, the mass attenuation coefficient is a weighted sum of the mass attenuation coefficients of the component elements, the weight being the fraction by weight of that element. Differences in linear attenuation coefficients among tissues is responsible for X-ray image contrast. In CT the function imaged is in fact the distribution of linear attenuation coefficients. For soft tissues, the linear attenuation coefficient is roughly proportional to physical density. For this reason, the values in a CT image are sometimes referred to as density.
• mass attenuation coefficient : loss of intensity per mass unit. It is defined as the linear attenuation coefficient divided by the density of the medium (r). For a given incident g-ray energy, the mass attenuation coefficient is independent of the physical and chemical state of the absorber. Thus, the mass attenuation coefficient is the same for water whether present in liquid or vapor form. The mass attenuation coeficient of a compound or mixture of elements, can be calculated by taking the weighted sum of the mass attenuation coefficients for each element, where weight is assicned according to the fraction of the element contributing to the compound.
Radiocontrast enhancement can eventually be used to detect lumen of visceral organs with no natural radiological contrast. Radiocontrast agents / contrast media (CM) may be :
• positive contrast media
• water-unsoluble contrast media (used in screenings)
• ₅₆BaSO₄ (Micropaque^®, Prontobario HD^®)

Side effects :
• colorectal perforation from enteroclysm
• chemical peritonitis
• prolonged retention in patients with constipation => bowel obstruction
• aspirationpneumonia, mediastinal baritosis
• styrene maleic acid neocarzinostatin (SMANCS) (Lipiodol^®)
• water-soluble or uroangiographic contrast media (used in emergencies and when fistulae are suspected : that's why when used for gastrointestinal X-ray they don't cause aspirationpneumonia as they can be expulsed with cough or aspirated or reabsorbed from tissues)
• iodized oil : an iodine addition product of vegetable oil; used as radiopaque medium in radiography of the uterus and uterine tubes.
• chloriodized oil : an iodine monochloride addition product of vegetable oil; formerly used as a radiopaque medium in hysterosalpingography, and radiography of the bronchi
• ethiodized oil (Ethiodol^®) : an iodine addition product of the ethyl ester of the fatty acids of poppyseed oil, used as a radiopaque medium in hysterosalpingography and lymphography.
• iodinated aqueous contrast agents (₅₃I)

		iodine to particle ratio	carboxyl group to iodine ratio	nr of hydroxyl groups per molecule (directly related with water solubility)	iodine content at 0.3 osm/kg H2O (mg/ml)	viscosity (37°C) (mPa . s) increases as the iodine ratio increases	osmolality at 300 mg iodine/ml (osm/kg H2O)	osmo- toxicity decreases as the iodine ratio increases	chemo- toxicity  = nr of carboxyl groups / nr of hydroxyl groups	IV dose tolerance
ionic monomers (high osmolality and chemotoxicity : untoward haemodynamic and electro physiological effects resulting from the presence of chelating agents)	diatrizoate : sodium amidotrizoate + meglumine amidotrizoate 10:66 (Angiografin®, Gastrografin®, Urografin® / Uroselectan®, Renovist®, Renovist II®)	3 : 2	1 : 3	0 (1 in ioxith.)	70-370	8.9	1.5-2.15	+++	+++	+
	iothalamate (Glofil®); meglumine iothalamate (Biligrafin®)
	ioxithalamate
	iodamide (Renovue-65®, Renovue-DIP®)
	metrizoate (Isopaque®)
ionic dimers	ioxaglate (Hexabrix® 320)	6 : 2	1 : 6	1	150	7.5	0.6	++	++	++
nonionic monomers	iomeprol (Imeron® 400) (without EDTA)	3 : 1	0	4-6	150-450	8.6-10	0.6-0.7	++	0	++
	iobitridol (Xenetix® 250 or 350)
	iopentol (Imagopaque®)
	iopamidol (Iopamiron®, Solutrast® 370)
	iopromide (Ultravist®)
	iohexol (Omnipaque®)
	ioversol (Optiray® 350)
	ioxitol
	metrizamide (Amipaque®)
nonionic dimers	iotrolan (Iotrol®, Isovist®)	6 : 1	0	9 or 12	300	11.4	0.29	+	0	++++
	iodixanol (Visipaque® 320)

• iopanoic acid (Cistobil^®, Colegraf^®, Neocontrast^®, Telepaque^®)
• meglumine ioglycamate (Biligram^®)
• propyliodone
• ipodate (Bilivist^®, Orografin^®)
• sodium ipodate (Biloptin^®)
• calcium ipodate (SoluBiloptin^®)
• iocetamic acid (Colebrin^®)
• tyropanoate sodium (Bilopac^®, Bilopaque^®, Lumopaque^®, Tyropaque^®)
• Graham's test : the intravenous or oral administration of iodophthalein sodium prior to radiographic examination of the gallbladder
Indications to use of nonionic contrast media :
• previous reaction to a contrast media (excepted heat flushes or episode of nausea or vomiting)
• asthma and other severe pulmonary diseases
• history of atopy (pretreatment with corticosteroid and antihistamines is recommended)
• age below 2 years
• renal failure or creatininemia > 177 mmol/L (> 2 mg/dL)
• cardiopathies (renal failure, severe arrhthmias, unstable angina pectoris, recent AMI) or pulmonary hypertension
• diabetes mellitus
• cachexia
Contraindications :
• manifest thyrotoxicosis
• iodine type I hypersensitivity : patients should be observed for a possible severe reaction during and for at least 30-60' after administration. Patients with previous allergic reaction to a contrast medium should be pre-treated as follows
• 12 hours before examination : prednisone (40 mg p.o.) or methylprednisolone (32 mg p.o.)
• 2 hours before examination : prednisone (40 mg p.o.) or