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Too much worry and mental tension is asso- Genetic Birth Defects may occur through three ciated with psychosomatic conditions like hypertension discount sinequan online amex anxiety grounding, mechanisms buy sinequan 25mg anxiety symptoms nail biting. Chromosomal disorders: Wherein the chromo- scientious person will ward off many accidents and infec- somes are abnormal in number or structure purchase cheap sinequan on-line anxiety knot in stomach, e sinequan 75mg with mastercard anxiety symptoms feeling unreal. Turner syndrome On the other hand, a person with an accident prone and fragileX-mental retardation. Single gene disorders: Which result from abnor- of mental health are further discussed in Chapter 34. More than 4300 monogenic Recent research has revealed some newer mecha- disorders in human being have been identified so far. There is evidence that a state interact with multiple exogenous or environmental of complete mental relaxation, as found in meditation factors to cause disease. Many of such disorders are and certain yogic asanas such as shavasan, is associated said to run in families but the inheritance pattern with increased alpha wave activity in frontal lobes and is complex. Examples are diabetes mellitus, gout, a positive effect on immune defense mechanism of the cleft lip, cleft palate, coronary heart disease, etc. It health and disease differentials in higher social classes grew from the realization that the central nervous versus lower socioeconomic groups. These may also be system and the immune system are intricately acting via genetic and constitutional factors of the host interlinked and have subtle interactions. Human explanation for the well known placebo effect and its genetics is slowly emerging as an important element in newly named counterpart, the so called nocebo effect. An example is afforded by two because they believe they will-has also been well recent discoveries around 1995-96. Genetic Constitution Inheritance and Expression of Genes Genetic factors play an important role in predisposition Genotype refers to the genetic constitution. Hereditary genetic constitution indicates what genes a particular defects, transmitted through genes, may be present at person has inherited from the parents. Huntington’s the outward expression or manifestation of the genetic chorea, Friedreich’s ataxia). It should be noted that the term ‘congenital’ depending upon the presence of A or B agglutinogens is not synonymous with ‘hereditary’. Phenotype characters like weight and preventive medicine is the prevention of blood group blood pressure may be influenced by environment but incompatibility. These are inherited in a simple Mendelian Transmission of Characters manner, with the result that the child will have specific antigen if one of the parents had it. There are many Genetic transmission of characters from one generation other hemagglutinogens in human blood of which Rh to the next may be altered because of chromosomal factor is the most well known. An example of chromosomal negative and the embryo is Rh positive (because of the abnormality is Down’s syndrome or Trisomy-21, which, father), the mother will develop antibodies against the in 95% cases, is due to nondysjunction during meiosis. An Rh negative mother should have producing a marked or easily observable effect, are the Rh status of the husband tested. Expectant mothers are Application of Genetic Principles now routinely tested for Rh negativity in antenatal clinics. It may be advisable not to marry or to produce children Improvement of health of the people by applying the in such cases. If the disease is due to a fully dominant principles of genetics comes under the domain of gene, the probability of the child inheriting it is 50%. It is the study and control of factors in the If it is due to a fully recessive gene the child will get the parents which affect the hereditary qualities of the disease only if both parents are homozygous for the future generation. Heterozygotes will be detected only if they have prevent hereditary diseases, the following measures already produced one defective child. Hemophilia is should be undertaken: due to a recessive sex linked gene transmitted by normal • Marriage guidance and genetic counseling at the mothers to male children. Girls from such families family welfare clinics: The aims should be: should not have children. The role of the agent, host and environmental factors – To discourage inbreeding or endogamy so as to is well understood in communicable diseases and the avoid mating of heterozygotes present in a family adoption of specific measures is easy. Such heterozygote mating is more likely to produce homozygotes with phenotypic expres- communicable diseases where current knowledge is sion of the recessive character. The obvious not adequate, such as essential hypertension and example is that of thalassemia which is fairly atherosclerosis, genetic factors often play an important common in some communities. Though genetic transmission may be difficult to ble that the heterozygotes who have thalassemia prevent, early detection of genetic defects can help should not intermarry. Once a or not when a recessive gene has appeared in person is diagnosed to have a genetic disorder, his one child. Newer techniques have now made it Defense Mechanisms possible to look for mutated genes in blood samples. The different tiers of body defense are3 physical and These gene increase the possibility of an individual developing cancer of the breast, colon and thyroid, chemical barriers, primary or innate defense among others. In case of melanoma, the concerned mechanisms (inflammatory response and phagocytosis) gene can be detected in swabbings from buccal and adaptive immunity. Physical and Chemical Barriers A few examples of early diagnosis are given below: The body is endowed with a thick horny layer of skin • Abnormally high uric acid level (uricemia) due to to protect it against the pathogens in the environment. Also, the fatty acids in serum have • A high proportion of sibs of a diabetes patient show bactericidal properties. In there is coincident hereditary tendency for hyper- addition to the body’s intrinsic barriers, the normal cholesterolemia and hyperuricemia. For saving life by instituting appropriate medical or surgical example: treatment. An example of surgical treatment is removal • Antibiotic suppression of normal gut flora predis- of spleen in essential thrombocytopenic purpura. First, the to prolongation of Salmonella carrier state; protein missing due to a genetic defect may be • Doderlein’s bacillus (probably same as Lactobacillus supplied, such as insulin in diabetes, gamma globulin in congenital agammaglobulinemia and hemoglobin (in the acidophilus) in vagina helps to maintain a low form of repeated blood transfusion) in beta thalassaemia. Thus the prevented to a large extent if they are kept on a low polymorphonuclear leukocytes, tissue macrophages phenylalanine diet from the very beginning. The and other phagocytic cells immediately come into action progress of disease can be considerably halted by and try to engulf and destroy the invading pathogen. These patients can In the majority of the ordinary circumstances the above be provided aids and taught skills that might facilitate mentioned mechanisms suffice in the control of their psychomotor function and increase their capacity 147 infections. To tackle such microbes, the body has evolved causes active stimulation or production of specific an adaptive defense system in the body called “the antibodies is called active immunization. The basic principles immunized animal or human being to another is called of its functioning are “specificity” and “memory. Active immunization can be used system specifically recognizes the pathogen, reacts in the prevention of various infectious diseases. If a repeat contact does take place, the when protection is required within a short period of a immune system launches a vigorous and very efficient few hours or days.

The diagnosis of an epigastric hernia is made on The methods of management that can be clinical grounds alone cheap sinequan 75 mg on-line anxiety symptoms severe. Most patients request operation because the swelling is often painful and noticeable buy generic sinequan online anxiety leg pain. No treatment Many patients with an incisional hernia may not Surgical repair even have noticed the swelling and are happy to Surgical repair is carried out under general anaes- live with it discount sinequan online mastercard anxiety symptoms 10 year old boy. It is essential to ness is caused by a diffuse overall thinning of the mark the level of the hernia on the skin before the surrounding tissues rather than a defect with a dis- operation as once the patient is anaesthetized the tinct edge buy sinequan 75 mg cheap anxiety symptoms ringing in ears. The mass is usually found to be mainly extra- peritoneal fat, sometimes with a small peritoneal Modification of life style sac, coming through a very small (2–5mm diam- Many patients know which activities make their eter) defect in the linea alba. If obese patients can be persuaded to lose The bowel is reduced and the obturator canal weight, their hernia will become smaller and less closed. If the mouth of an obturator hernia is noticed during a laparoscopic repair of an inguinal hernia it can be covered by the same mesh used to cover the Support inguinal defect. A properly fitted support belt will control and Lumbar herniae sometimes follows trauma to alleviate the pain of many abdominal incisional the abdominal wall. Surgical repair Gluteal herniae are extremely rare and usually Surgical repair is indicated to relieve symptoms develop through a defect in the pelvic floor after and treat complications, e. Repair is difficult and in emergency situations the patient should be involves the insertion of a mesh by an open or reasonably fit, aware that the procedure is a major laparoscopic approach. If not, clinical into the abdomen by successive lines of non- diagnosis is straightforward. It is a congenital hernia absorbable sutures covered by a thin transparent membrane formed tension-free mesh repair, placing the mesh from peritoneum and the remnants of the coverings between the peritoneum and the abdominal of the yolk sac, which may have virtually no thick- wall, or as an onlay ness or strength and rupture spontaneously. This with an exomphalos do not survive, usually because may be technically demanding and covering of the presence of other congenital anomalies. Spigelian herniae occur at the edge of the rectus Gastroschisis is another rare neonatal abdomi- sheath. They usually present as a diffuse bulge and nal wall defect, which is not at the umbilicus and do not have a narrow neck. It is easier to repair and the content to live with the appearance once they know prognosis is better. Repair by an open method can be difficult because there is a general attenuation of the sur- rounding tissues. An umbilical fistula that discharges mucus or faeces Obturator herniae usually present with small and presents in early childhood is usually caused by bowel obstruction in a slim elderly woman, and are a persistent patent vitello-intestinal duct. Almost invariably the patient has many other symp- A patent urachus that discharges urine may also toms and signs, looks unwell and has lost weight. Treatment should be that appropriate for lation of a radio-opaque contrast medium into the whatever disseminated cancer is found. Surgical treatment is to explore the fistula This exceedingly rare condition should be sus- through the umbilicus and excise the track and the pected if there is a history of cyclical pain, swelling diverticulum (see Table 16. If it does hypotension are likely to be present and should be not, the old-fashioned method of applying silver investigated, as described in Chapter 18. Cullen’s sign – umbilical bruising – is discussed An umbilical adenoma is an isolated patch of in the section on pancreatitis (see Chapter 17). It may also be found in any condition associated The discharge it produces does not resolve sponta- with extraperitoneal bleeding. Contrast X-rays should be used to confirm features will be those associated with its underlying that there is no connection with the gut. Simple cause, which will indicate the investigations and surgical excision is curative. Burnand This chapter concentrates on patients presenting Most patients with gastric, biliary and pancreatic with abdominal pain. Their signs are described in full The conditions that present with nausea and in Symptoms and Signs and their investigation and vomiting are discussed in Chapter 18. But not all Vomiting upper abdominal pain is exacerbated by eating and Haematemesis some conditions such as carcinoma of the stomach Weight loss may be painless or, in the case of some forms of Jaundice pancreatic disease, just cause a chronic persistent epigastric discomfort. Distention The investigation and management of the many Colic conditions which present with abdominal pain as their main symptom are described in this chapter. It is impor- Acute cholecystitis and biliary colic tant to differentiate regurgitation from vomiting. Peptic ulcer disease including perforation Anorexia and nausea Small bowel obstruction Gynaecological disorders Anorexia (a loss of appetite) and nausea (a feeling Acute pancreatitis of sickness or queasiness that makes the patient feel that they are about to vomit) (Chapter 18) Renal and ureteric colic are caused by many different diseases, within Malignant disease and without the abdomen. Vomiting is caused by many different diseases, A history of considerable weight loss suggests many outside the abdomen, including disorders of the possibility of a gastric carcinoma. Patients with alcoholism are more likely to bleed from peptic ulceration than oesophageal Types of vomitus varices but both conditions should be considered when excessive alcohol use is discovered. Alcoholics Vomitus free from bile, in children, is likely to be with oesophageal varices have an associated cirrho- caused by congenital pyloric stenosis. This vomiting sis of the liver and so may have the stigmata of liver is described as projectile in that it spurts effortlessly disease such as spider naevi, palmar flushing and from the mouth. Vomiting that does not contain bile, in adults, Bleeding disorders, antiplatelet drugs and anti- and often contains undigested food such as tomato coagulants should always be excluded. A similar type of vomitus may occur in patients The passage of dark blood per rectum is usually with a pyloric gastric carcinoma. Vomiting associated with small Weight loss bowel obstruction or from a paralytic ileus con- tains bile but the presence of bile in vomit is not Weight loss (Chapter 18, page 434) is common in particularly discriminating, apart from ruling out patients with upper alimentary system symptoms. A combination of dysphagia and weight loss suggests Faeculent vomiting occurs in patients with a malignant tumour of the oesophagus or cardia. A prolonged small bowel obstruction and rarely in history of a marked weight loss and vague dyspepsia patients with large bowel obstruction (often right- is highly suggestive of a pancreatic carcinoma, espe- sided bowel cancers). It can also occur with a gas- cially a tumour arising in the body or tail of the gland. Jaundice Haematemesis Jaundice (Chapter 18, page 437) is a yellow pigmen- Haematemesis (Chapter 18, page 463) is vomitus tation of the skin and sclera caused by an increase in containing blood. The blood may be just a faint the level of the serum bilirubin commonly caused ‘blood staining’ or it may be frank blood. The blood by an obstruction of the biliary system but also by may be dark if it has been in contact with gastric liver disease and increased haemolysis. Patients who have had a haematemesis are usu- Distension ally unreliable witnesses with regard to the volume of blood they have vomited. The abdomen may be distended by fluid within the A history of dyspepsia or prolonged exposure peritoneal cavity or by the enlargement of any of to steroids or the non-steroidal anti-inflammatory the organs within it. The causes of ascites are listed drugs that are known to be associated with acute in Table 18. The ‘acute abdomen’ 373 Colic Colic is an intermittent griping pain originating from the muscle layers of hollow obstructed con- Peptic ducting viscus such as the small and large bowel Hepatitis Splenic nfarct ulcer and the ureter.

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John has had increasing (c) Empyema dyspnea for the past 3 years with associated occasional (d) Bronchogenic carcinoma cough but little sputum production cheap 10mg sinequan amex anxiety medication side effects. Which of the following is the characteristic feature of (c) Diffuse alveolar damage adult respiratory distress syndrome? A 65-year-old smoker Sutta Ram with hemoptysis (c) Alveolar exudates and weight loss undergoes a left upper lobectomy for (d) Interstitial fbrosis squamous cell carcinoma proven 25mg sinequan anxiety symptoms in 5 year old boy. Anthracotic pigments deposited heavily (b) Size of the particle ingested is more than 0 purchase sinequan 25 mg online anxiety symptoms vision. These fndings are most eter compatible with (c) Combines with lysosome forming phagolysosome (a) Asthma (d) Amoeba and other unicellular organisms make their (b) Chronic bronchitis living out of it (c) Emphysema 30 discount 75mg sinequan with amex anxiety pill names. A 52-year-old male smoker Naresh presents with fever (b) Pneumoconiosis and a cough productive of greenish-yellow sputum. In emphysema, the destruction of many alveolar walls (d) Mesothelioma changes the compliance of the respiratory system. Which of the following is characteristically not Which of the following clinical observations is directly associated with the development of interstitial lung related to this change in compliance? Which of the following is associated with hypersensitive (c) Sudden infant death syndrome pneumonitis? Pleural calcifcation is found in all of the following (d) Bronchoconstriction except: (Bihar 2003) (e) Response to steroids (a) Asbestosis 39. Which of the following inhaled occupational pollutant (b) Hemothorax produces extensive nodular pulmonary fbrosis? Acute pulmonary sarcoidosis is least likely to be asso- (c) Adenoma lung ciated with: (Bihar 2004) (d) Mesothelioma (a) Uveitis (b) Pleural effusion 41. A 40 year old air-hostess man has experienced increa- sing respiratory diffculty for the past 18 months. Her chest X-ray is highly suggestive of 422 Respiratory System diffuse interstitial disease without any abnormal mass (c) Silicosis or hilar lymphadenopathy. Oja Jesu who fnds that he is not having any (c) 20-30% abnormality on physical examination. On sectioning of an organ at the time of autopsy, a (a) Antigen – antibody complex formation focal, wedge-shaped frm area is seen accompanied (b) Release of histamine by extensive hemorrhage, with a red appearance. A 44-year-old woman presents with insidious onset of (b) Heart with coronary thrombosis shortness of breath, chest pain, and fatigue. Chest x-ray (c) Liver with hypovolemic shock flms reveal bilateral pulmonary infltrates and enlarged (d) Kidney with septic embolus hilar lymph nodes. All are the histological features of pulmonary hyper- exposure to mineral dusts or organic dusts. Which of the following 423423 Review of Pathology symptoms is most likely associated with these patients? A 42 years old woman Sugahi Ramamurty has a 3 month (d) Left upper lobe history of mild persistent left sided chest pain. A (c) Small arterioles are blocked biopsy taken after thoracotomy demonstrated the mass (d) Most of the emboli cause infarction being composed of spindle cells resembling fbroblasts with abundant collagenous stroma. A 67 yr male with history of chronic smoking hemoptysis smoking history presents to the emergency room with cough. Bronchoscopic biopsy from centrally located with complaints of dyspnea and truncal, arm, and mass shows undifferentiated tumor histopathologically. A patient Rasool is brought to the emergency room (d) Microvilli invasion following a seizure. Serum electrolyte studies (e) Intense fbrosis demonstrate serum sodium of 128 mEq/L. Neuroendocrine lesions of lung are: osmolarity is higher than the serum osmolarity. Which of the following (b) Alveolar carcinoma forms of lung cancer is most likely to cause the described (c) Hamartoma electrolyte imbalance? Cavity formation is observed in one of the following cardiac sounds on left side of the chest but surprisingly bronchogenic carcinoma: the normal heart beat on the right side of the chest. All give rise to malignancy except (a) Down syndrome (a) Cholelithiasis (b) Bronchiectasis (b) Kartagener syndrome (c) Ulcerative colitis (d) Paget’s disease (c) Kawasaki disease (d) Marfan syndrome 74. A patient with small-cell carcinoma of the lung (b) Impaired neurological development complains of muscle weakness, fatigue, confusion, and (c) Pneumonia in child weight gain. Which of the following is seen on (b) Decreased plasma vasopressin concentration electron microscopic examination? Which of the following is having the minimal chances (d) Berylliosis of causing a mesothelioma? The most common lesions in the anterior mediastinum (a) Bronchial adenoma are all except: (b) Bronchial carcinoid (a) Thymomas (c) Hepatic adenoma (b) Lymphomas (d) Villous adenoma (c) Lymph node enlargement from metastasis 74. Least common cause of clubbing is: (b) Silicosis (a) Adenocarcinoma (c) Byssinosis (b) Squamous cell cancer (d) Anthracosis (c) Small cell cancer (d) Mesothelioma 74. Caseous granulomas with multinuclear giant cells are present in both primary and secondary tuberculosis. It may occur postoperatively, or may complicate bronchial asthma, chronic bronchitis, aspiration of foreign body etc. Microatelectasis It can occur postoperatively, in diffuse alveolar damage, and in respiratory distress of the newborn from loss of surfactant. Contraction atelectasis It occurs when fbrous scar tissue surrounds the lung preventing its full expansion. Mycobacterium tuberculosis frst localizes in the lung parenchyma, then in the hilar lymph nodes. These lesions usually heal by fbrosis, leaving only small scars at the sites of remote tuberculous infection. Reactivation of dormant bacilli in old lesions or additional re­exposure leads to secondary tuberculosis, with progression of lesions. Resorption Atelectasis Compression Atelectasis Contraction Atelectasis • Due to airway obstruction leading to resorption • Due to presence of fuid, blood, • Fibrosis in the lung or pleura preventing full of oxygen trapped in the alveoli. Early in infection, tuberculosis bacilli replicate essentially unchecked, while later in infection, the cell response stimulates macrophages to contain the proliferation of the bacteria. It increases in some disease states due to increase in plasma fbrinogen, immunoglobulins and other acute phase reactants. A key clue in the stem of the question is the plasma protein electrophoresis fnding suggesting α-l-antitrypsin defciency. John point to an obstructive lung disease like emphysema which occurs due to airway narrowing or even from loss of elastic recoil. It is characterized by thickening of the arterial smooth muscle with intimal hyperplasia and fbrosis. Atherosclerotic changes in the normally plaque-free larger pulmonary arteries may be seen. Hyperplasia and hypertrophy of mucous glands in chronic bronchitis causes increased Reid index in these patient.

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Altering the dynamic range allows subtle changes within tissues to be differentiated discount generic sinequan canada anxiety medicine for dogs. If the image is degraded by low-level noise or artifacts best 10mg sinequan anxiety disorder symptoms dsm 5, reducing the dynamic range can improve the overall image quality (Figure 2 75 mg sinequan for sale anxiety symptoms full list. Zoom Magnifies the region of interest best purchase sinequan kitten anxiety symptoms, but the image can appear “grainier” (Figure 2. For practical purposes, when altering the sector width it is important to achieve a careful balance between good spatial resolution and a field of view that is not clipped too tightly, so that the relationship of the region of interest and surrounding structures may be assessed. Most ultrasound machines have a cine loop function whereby using the tracker ball, the operator can scroll back through the preceding several seconds of the scan, frame by frame. This allows a series of images to be reviewed and the most appropriate image stored. Calipers Once an image has been captured and frozen on the screen, the caliper control allows the distance between two points to be measured. This is a “get out of jail free” control that can be used if manual control adjustment doesn’t improve the image quality adequately. When sound strikes a moving object a Doppler shift Traditionally, red represents blood flow moving occurs. This is the change in the perceived frequency toward the probe and blue away from the transducer relative to the transmitted frequency. It is important to remember that on the angle, velocity, and direction of blood flow. If the the sound wave is perpendicular to the moving object, Doppler flow signal is poor, a pulsed wave can be no Doppler shift occurs. It is more sensitive than color Doppler, as the returning echoes from the blood cells are analyzed by their power spectrum instead of by frequency shift. Christensen’s physics of different degrees of adjusting to achieve a diagnostic diagnostic radiology. The focal zone (a)-white triangle adjacent to the measurement scale-is also set too deep. Jones is called to the intensive care ing on whether the procedure is elective or emergent, unit at 2 a. However, the patient is obese and has multiple limb fractures, increasing the difficulty of chest drainage. She places a mark on the patient’s skin, with appropriate distances measured with ultrasound, so that she can immediately insert a chest tube with minimal risk of complications. Each environment presents unique technical challenges to the successful acquisition of an optimal image of thoracic anatomy and pleural pathology. This chapter will summarize common prin- ciples and practical suggestions that will guide you to V achieve optimal ultrasound imaging and interpretation Video 3. This is because pleural effusions are mobile and tend to move to the most dependent part of the pleural space. In a patient who is ambulatory, positioning the patient erect will generally give the best diagnostic results. In this position, fluid will preferentially accumulate in the posterior costophrenic recesses, where it can be readily seen from a posterior approach. Additionally, the liver and spleen can be easily identified, serving as landmarks. The easiest way to achieve this position is to sit the patient on the edge of a bed or on a stool, leaning slightly forward, with a pillow on their lap. The scapulae are moved forward so they do not obstruct the ultrasound exami- nation. This is often the optimal patient position for diagnostic ultrasound (Scenario 1). If an intervention is planned, optimal positioning also considers procedural access. Sometimes, several dif- ferent degrees of obliquity of patient position need to be tried to facilitate movement of pleural fluid, so there is a sufficient depth of fluid at the site requiring procedural access. Therefore, the patient needs to be rolled toward the lateral decubitus position (Figure 3. In this position, fluid in the uppermost hemithorax will preferentially accumulate medially adjacent to the spine, but larger effusions usually also extend superiorly from the lateral costophrenic recess, as well as anteriorly. The ultrasound probe can readily access the lateral and posterolateral aspects of the uppermost hemithorax to guide inter- vention (Scenario 2). If no movement is seen on tures such as the scapula that will obstruct the ultra- the screen, check that any screen freeze/ sound beam. Small changes in position and posture can hold function is off, and that the 2D gain is adequately turned up. Clothing can prevent adequate probe travel, and ultrasound gel tends to leave salty marks, which don’t wash out easily. Covering the patient’s waistline with a towel is also recommended to protect clothing from gel. Ultrasound machine and probes ●● Ensure you have access to an adequate power ●● Select the correct preset on machines that have supply, and that the electrical needs of the ultra- this feature. Advanced machines have multiple sound machine will not exceed local capacity presets that affect the way the image is processed (especially relevant in environments with by the machine. The abdominal preset is usually multiple electrical equipment such as intensive optimal for pleural ultrasound. Upper left: curvilinear c5-1 probe uses frequencies 1–5 Mhz and is good for scanning effusions. Upper right: linear l12-5 probe uses frequencies 5–12 Mhz and is better for superficial structures, including the chest wall. When integrated with clinical information, this will ensure the aim of the pro- cedure is clear. This is particularly important if focal pleural lesions or loculated collections are suspected, so the examination can be tailored. Review of recent imaging also prevents any possible errors (for example, scanning the wrong side if patients have bilateral effu- sions). Scanning environment and ergonomics ●● Appropriate background lighting optimizes viewing conditions for the screen and avoids glare. Where possible, use dimmable lighting with window blinds and curtains to exclude natural light. In general, the patient, machine, and operator or even film viewing box close to the scanner should be in an equilateral triangular arrangement, so is helpful to assist in correlation of radiology, that the operator has comfortable equal access to the as well as comparison of previous ultrasound patient and the machine. Patient region to be scanned at optimal height for the Experienced operators hold the probe in various operator ways. We suggest the following guides to assist you to if doing prolonged scanning, vary between sitting and hold the probe so that firm pressure can be comfort- standing ably applied in a controlled manner, but probe angle Ensure the operator is comfortable while scanning, and position can be easily and precisely adjusted: with no strain Source: furlow B, Radiol Technol 2002;74:137–50; quiz 152–3, 135–6. The thumb and index finger are as close to the probe face as possible, with the little finger maintaining tactile contact with the patient. It is best and This places the thumb and index finger as close easier to place gel on the probe rather than to the transducer face as possible, where they can the patient.