Sarcoidosis: Causes, Symptoms, and Treatment -

Sarcoidosis: Causes, Symptoms, and Treatment -

Sarcoidosis: Causes, Symptoms, and Treatment -

Hi, hello and welcome back to one of the most must-see Web Site for all the Medical students across the globe, we're going to see about sarcoidosis Let's begin! Before reading this article, if you have not subscribed to my Web Site already, please press the subscribe button and the bell icon nearby to be notified as soon as I upload a new article.

So sarcoidosis it is a disease of unknown aetiology, which means the cause of the disease, is not exactly known. And there is multi-organ involvement in sarcoidosis. Which means various organs are involved in the patients of sarcoidosis. This shows the common involvements in sarcoidosis the patient can have organ involvement starting from head to toe anywhere and everywhere for example here you can see in this patient there are brain complications which are marked in the top and there are few skin lesions which are marked in the legs such as an erythema nodosum so there can be symptoms and signs anywhere in the body.

The most commonly involved organ in sarcoidosis is lungs which will lead to the development of granulomas and finally, development of nodules so let's see about individual things one by one and we'll get a clearer area of sarcoidosis. So sarcoidosis is a systemic granulomatous disease, which means there will be the formation of granulomas in multiple organs in the body. Now, what is granuloma? Granuloma is one of a manifestation of chronic inflammation This type of granuloma is non-caseating so there are many diseases in which the formation of granulomas along with caseous necrosis But in this condition, in sarcoidosis, the granulomas are non-caseating which means there'll be granulomas but there won't be caseous necrosis now.

This is a microscopic picture of granuloma as you can see here there are multiple cells over here which looks like epithelium dispersed throughout the slide they're actually activated macrophages which are known as epithelioid cells and you can see a big cell with multiple nucleus at about 10 O'clock position that is a multinucleated giant cell so these are the main features of granulomas so how do the patients present in case of sarcoidosis most commonly the patients are asymptomatic they come to be diagnosed with sarcoidosis mostly by a chest x-ray and on chest x-ray, we can find the nodular... 

Presence of nodules on the lungs or we can see hilar lymphadenopathy so they can also present with respiratory symptoms because of lung involvement and erythema nodosum and arthralgia which are skin and joint involvements are common in many patients ocular symptoms such as uveitis which can lead to pain, blurring of vision and all that can occur in these patients skin involvement is also common. Superficial lymphadenopathy which means enlargement of the lymph nodes around the neck are also common and there can also be other some other symptoms or other signs such as elevated calcium levels in the blood which is called as hypercalcemia and there can be hepatomegaly which is an enlargement of the liver and splenomegaly which is an enlargement of the spleen So now let us see the pathogenesis of sarcoidosis is not clear.

Known as I told you earlier it is a disease of unknown aetiology but it has been thought that there is the cause of sarcoidosis is due to immune dysregulation in few genetically predisposed individuals so in few people who are genetically predisposed there is some sort of immune dysregulation which will lead to increased CD4 positive T helper cell activity okay so this activity of the CD4 positive T helper cells increases and they start to produce a lot of cytokines such as IL-2, interferon-gamma, interleukin 8, tumour necrosis factor etc.

All these are pro-inflammatory and they increase the inflammation leading to the development of granulomas so what happens is there will be multiple granulomas formation over organs such as lungs liver spleen etc. and all these granules coalesce together to form consolidation and the consolidation enlarges to form nodules which are about one to two centimetre in size and they are palpable so the nodules are most commonly seen in lungs liver and spleen of patients of sarcoidosis The most common finding in about 90% of the cases of sarcoidosis is bilateral hilar lymphadenopathy which means lymphadenopathy or disease or enlargement of the lymph nodes which are present around the lungs so this is the most common finding in about 90% of the patients of sarcoidosis so this is the gross appearance or gross picture of bilateral hilar lymphadenopathy As you can see here the hilar lymph nodes are so much enlarged in this picture This is one of the most common findings in sarcoidosis. 

So the nodules as I told you earlier is formed by the consolidation of various granulomas The granulomas which are present at nearby sites join together or coalesce together to form a consolidation and that will join together to form nodules The nodules are most commonly seen in lungs, spleen and liver. As a result of that slowly the liver begins to enlarge in size leading to the development of hepatomegaly the spleen also enlarge in size which is also known as splenomegaly Skin lesions are very common, say, very common in the patients of sarcoidosis Various types of lesions can occur in the skin of these patients they can be erythematous plaques which are red lesions present on the skin or they can be various other types of skin lesions in these patients which can be one of the factors which bring the patient to the doctor.

The most common skin lesion which is found as a patient of sarcoidosis is erythema nodosum Erythema nodosum is actually not a disease of skin per se, not the upper layers of the skin It is the inflammation of the subcutaneous tissue which is present under the skin which should lead to a presentation of somewhat like this you can see red lesions on the skin if you palpate them, you can actually feel the raised surface around normal skin surface This is the common presentation of sarcoidosis Eye involvement is also very common in these patients The most common association of sarcoidosis in relation to the eye is something known as uveitis which is inflammation of the uvea which is the vascular coat present inside the eye The uvea includes three divisions such as Iris, ciliary body and choroid. 

All this individually or together can be inflamed leading to conditions such as iritis, iridocyclitis, etc., On long-standing cases, there can be corneal opacity glaucoma and all these worsen to develop total vision loss Vision of the patient can be affected so severely Lacrimation is also suppressed in these patients because we all know that lacrimation in the production of tears from the lacrimal gland so what can happen is sarcoidosis can affect lacrimal glands also there can be granuloma formation in sarcoidosis which can affect its function so tears production can be affected This can lead to decreased lacrimation in these patients Musculoskeletal system is also involved in few patients. There can be muscle weakness, tenderness and fatigue of the muscles. 

This can be brought out in patients.. in few patients of sarcoidosis In most of the cases, this is not the presenting complaint in most of the patients if you're gonna see they're gonna present with respiratory symptoms, skin lesions or eye problems but this is not one of the major complaints. You need to ask history regarding this to bring this out to light Okay? So this is accompanied by arthralgia which is the pain of the joints It can involve bones also. Most commonly involved bones are the bones which are present in the phalanges of hands and the phalanges of feet Now let's see about the treatment of sarcoidosis. In mild cases, if there is an acute attack of say erythema nodosum or some other complications we can treat that with NSAID's and low dose corticosteroids okay. So, if there are increased respiratory symptoms such as which can be due to increased involvement of the lung. 

We can increase the dose of corticosteroids Increasing the dose of corticosteroids can help in those cases but in severe cases, you need to treat the patients severely with drugs such as methotrexate, azathioprine which are immunosuppressant actually they are anti-cancer drugs, okay so these drugs are associated with increased side effects or let's say adverse drug reactions such as alopecia which is hair loss and so the treatment of severe cases can itself lead to various other complications So if you liked this article, please leave a LIKE Share this article to your friends and give your valuable suggestions in the comment section below. 

Kidney Disease: Understanding Your Lab Values

Kidney Disease: Understanding Your Lab Values  

We'll talk about laboratory values for chronic kidney disease it is important that you track and understand your lab values we already talked about creatinine in the previous module creatinine is a waste product from the muscle which is normally removed by the kidneys the level in the blood rises when kidneys do not function well GFR or glomerular filtration rate is calculated based on your creatinine and it estimates the percent of normal kidney function blood urea nitrogen also known as BUN or some patients like to call it Bun it's a waste product from dietary protein which is removed by the kidneys BUN or bun is also used to estimate the level of kidney function but it is less reliable than creatinine it can be affected by how much fluid one drinks and some other variables.

We prefer to focus more on creatinine let's move on to electrolytes and acid-base balance in the blood most people know that too much sodium is not good for you, unfortunately, the level of sodium in the blood does not reflect how much sodium you're eating you might be eating three times as much as you should as an average American does yet your measured level will remain normal at the expense of drinking more fluid to dilute this extra sodium and possibly elevating your blood pressure and putting extra strain on your heart some people can, however, develop an abnormal level of sodium in the blood due to either poorly functioning heart or kidneys or liver or some hormonal disturbances normal level of sodium is between 135 and 145 potassium is a mineral in your blood.

That helps your heart and muscles work properly if the level is too high it can change your heartbeat and lead to potentially dangerous arrhythmia normal range is between three point five to five-point one if potassium level in your blood gets to be too high we'll educate you how to avoid foods which are high in potassium and use medications to help maintain healthy potassium level now bicarbonate is a measure of the acidity of your blood patients with chronic kidney disease often cannot excrete acid generated from the metabolism of foods that they ingest mainly it comes from protein and they develop metabolic acidosis so what metabolic acidosis big deal right well it is a big deal metabolic acidosis also known as too much acid or too little base can lead to muscle breakdown no one wants to have weak muscle right it can also lead to weak bones.

It can speed up the progression of chronic kidney disease normal value for bicarbonate is between 22 and 29 if your level is below that your nephrologist might prescribe baking soda or similar type of medication to correct it to neutralize extra acid in your body and thus protect your muscle protect your bones and slow down the progression of chronic kidney disease, the next three laboratory values have to do with bone health they can be are adversely affected by kidney disease and lead to weak bones calcium and phosphorus are important for strong bones abnormal levels of calcium and phosphorus besides leading to bone disease believe it or not they can get deposited in your blood vessels heart and other organs and cause damage as well normal levels for those minerals might slightly vary depending on the laboratory.

But usually our eight-point six to ten point five milligrams per deciliter for calcium and two-point seven to four point five for phosphorus we will help you maintain normal calcium and normal phosphorus levels with appropriate diet and if needed we use some medications now parathyroid hormone also known as PTH and not to be confused with thyroid hormone or TSH this is something different so PTH regulates the movement of calcium and phosphorus between your blood bones and also affects the excretion in the urine the acceptable level for PTH depends on the stage of kidney disease so you will have to check with your doctor what's the appropriate level for you if your PTH gets to be too high will prescribe a special type of vitamin D which will bring it down to more healthy levels we are moving on now to laboratory values for anaemia haemoglobin is part of red blood cells that carries oxygen from your lungs to all parts of the body haemoglobin is used to diagnose anaemia.

The target range for haemoglobin in patients with CKD is somewhere between nine points five to eleven and it's kind of a moving target but for now, this is what it is if your haemoglobin level is below this range your doctorate might prescribe special medication that will help you your body produce more blood we also periodically measure your iron stores are very important iron is a necessary building block for red blood cells should you be iron deficient your doctor will likely prescribe either iron pills or intravenous infusion to correct this deficiency let's talk about cholesterol for a moment everyone knows about cholesterol right cholesterol is a fat like substance that is found in all cells of the body your body certainly needs some cholesterol but if present in excess it can lead to heart disease normal cholesterol level is considered to be under 200 there are two basic types of cholesterol HDL also known as good cholesterol you get a smiley face for this it has protective properties to the heart so you want this number pretty high one of the ways to increase HDL is by exercise and we'll talk about this more LDL also known as bad cholesterol does not get a smiley face.

It can contribute to heart disease so you want this number on a lower side your doctor might ask you to take cholesterol medication even if your level of cholesterol is under 200 so normal right there is the reason is that patients with CKD are at high risk for heart disease regardless of cholesterol level as I mentioned in the previous module protecting your heart is our number-one priority yes we're kidney doctors yes we care about kidneys but heart comes first a triglyceride is another type of fat found in your blood and if elevated it might increase your risk of heart disease it's usually measured at the same time as measure cholesterol we are now down going over various blood tests and are ready to focus on testing of the urine in the normal state of kidney health there should be no blood no protein and no bacteria in the urine nothing like that presence of blood or protein cannot be detected with a naked eye.

That's why we asked you to submit a urine sample to the lab for more precise microscopic measurements if your kidneys are spilling protein in the urine we'll run an extra test to quantify how much protein is being wasted protein in the urine also known as proteinuria if you want to sound like a nephrologist can overtime cause damage to your kidneys whenever possible we use medications to decrease the amount of protein in the urine and to protect your kidneys besides checking blood and urine tests your nephrologist will likely want to have a picture of your kidneys this is done to make sure that you have two kidneys yes some people are born with just one kidney and they don't know about this it's an incidental finding and we also want to make sure that there is no obstruction or abnormal cysts in your kidneys depending on your situation.

Your you might be asked to do either a kidney ultrasound which is pretty simple or a little bit more sophisticated tests like cat scan or even MRI let's do two questions to test your understanding of this module question number one what blood tests do we use to estimate the level of kidney function or GFR is it a sodium or B potassium or C creatine or D phosphorus all right let's think about this for a second and the correct answer is C or creatinine is used to calculate GFR all right are you guys ready for question number two how much protein should be present in the urine option a none option B some but not too much and let's see option C the more the better all right which one is it okay and the correct answer is that there should be absolutely no protein in the urine protein in the urine is a risk factor for worsening kidney function over time we do everything we can to minimize the amount of protein in the urine congratulations you have completed the module on laboratory values for chronic kidney disease. 

Complete Blood Count / CBC Interpretation (Leukocytosis)

Complete Blood Count / CBC Interpretation (Leukocytosis) 

The first in the series that we're going to talk about as we go through the CBC is the WBC and we'll talk about increased WBC here under the term leukocytosis okay so a couple of points regarding leukocytosis you know we're looking at a patient most typically in the hospital but this could also be seen as an outpatient as well you should know that the normal range is about 4.5 to 11 and then you'll have this term times 10 to the 9th which is like a billion divided into one litre so how many cells you see in one litre so obviously anything greater than 11 is going to define leukocytosis, okay but it can go as high as a hundred thousand you want to watch trends as we talked about in the first article so you know a 13 on a white blood cell count may be elevated but if the previous one was 20 and it's coming down to 13 then that's a process that's actually resolving and 13 is not to be worried about if on the other hand.

You've got a 5 and it's going to 13 that's something that obviously we need to worry about more okay so again as always watch the trends and then differential so the white count as you may know our white blood cells that are what the Leuco means that's white so these white blood cells are part of your immune system but these white blood cells are actually a collection of other cells there are bands there are segmented neutrophils we call those CEG's and these all sort of make up your neutrophils but then you also have lymphocytes you have monocytes you also have eosinophils, okay so they all have their own the function typically the bands and the neutrophils are seen elevated in pyogenic infections lymphocytes can also be elevated but they're usually more typical for viral okay so be aware of that.

You also may see this in tuberculosis same with monocytes you might see monocytes elevated in tuberculosis and also certain viral infections the one that you should know about though is eosinophils anytime you see elevated eosinophil you need to think about two things specifically one is either an allergy also think about parasites so think about drug allergies if you see high eosinophils think about parasites and there's also a third thing that you should think about is well I'll put it up here and this is just to keep in the back of your mind is Coxie coccidia mycosis which is a fungus that typically lives in the Southwest United States also in parts of South America Central America and that's a famous one that they like to use I bring it up.

Because that's where I live in this part of the world where we see coccidia mycosis and Yoson Affiliate is a nonspecific thing that you might see but think about Coxy think about allergies think about parasites if you see elevated eosinophil there are other things that can do it but that's one of the things that can do it but the one that you're probably going to see the most are these bands CEG's neutrophils and that will be elevated in pyogenic or bacterial infections and there's usually a range so typically what you would see in terms of percent is maybe about 60 percent will be bands and CEG's maybe about 22 or so percent and this won't add up to 100% but around 20 percent or so for lymphocytes about 5% for monocytes.

Maybe 2 to 4% for yo Sinha fills okay if you see a deviation from that then you know that there is a simple line that is increased so if this lymphocyte all of a sudden shoot up think about viruses if these segments go from 60 to 80 or 90 think about a pyogenic or bacterial infection if instead of 4% you're at 20% start thinking about what we talked about Coxy allergy or parasites so we talked about what's normal we talked about watching the trend we talked about the differential let's talk about causes and what to do if the white count starts going up on you on a patient in the hospital so in terms of causes the big four that I want you to know our infection steroids cancer/leukaemia or a catastrophic event and these are kind of listed in order of the most common.

Let's talk about infection first so typically with infection you're gonna see something called a left shift and what that means simply is that bands are basically released from the bone marrow and then it becomes segmented in neutrophils okay otherwise known as PM ends what happens is you see of very little bands and a lot of CEG's normally and when you have an infection the bands start to be released more and more and so you see the bands start to go up in circulation, they'll actually tell you how many bands there are if you start to see bands in circulation that's a very good indication that what you're dealing with an elevated white count is an infection the things that you want to look for clinically look for fever that will also tell you that that's what it is that's going on the look for signs of infection.

Okay, the other thing to do is ask the patient do they have pain that's usually a sign that there's an infection somewhere so look for corroborating evidence that there is an infection going on if you can't find it start to do diagnostic tests to confirm it so things that might be able to do it chest x-ray get a urinalysis you might even need to get a CT scan to look if the patient has a fever and is altered by all means get a lumbar puncture to rule out meningitis the biggest infections are pneumonia which you'll see on a chest x-ray a urinary tract infection which you'll see on a urinalysis look at their skin see if they've got cellulitis somewhere examine their belly see if they're tender think about cholecystitis think about diverticulitis all of these things are going to cause an elevation in the white blood cell count okay.

The other thing that you'll see is steroids so a lot of time people will come in and they'll need steroids for either a COPD exacerbation or they'll need steroids for an asthma exacerbation and you'll put patients on stage for whatever reason what you'll notice almost invariably is the WBC count is going to go up now why does the WBC count go up it goes up for three reasons and this will help us decide and distinguish between why it might be an infection, okay the first reason is something called D margination what does this mean here's your vessel with the white blood cells the middle of it what you don't realize is that their white blood cells have already adhered to the wall and so what happens is the steroids cause these cells to come into the centre of the blood vessel so when you draw the blood.

You're gonna get more of those white blood cells in your sample that's de margination about 60% of the effect that we see with an elevated white count is from D margination now the other thing that might cause this is delayed migration so everybody knows that these white cells go out of the blood vessel and into the tissue that's where they fight infections in the tissue well if you delay that migration of cells of white blood cells into the tissue they're going to be more likely to be in the blood vessel when you draw the blood and get the leukocytosis and we see that about 30% of that effect is due to that the last one that we see here is about 10% of the effect and that is bands released from the bone marrow but this is such a small proportion of the reason.

Why the white blood cells go up so small that in fact, we can actually look at this situation and say that if you see the bands going up significantly it's probably not from steroids it's probably an infection and that if we see all of the different white blood cells going out, for instance, we see the lymphocytes and the neutrophils and the monocytes and they're all going up proportionately that's usually a result of D margination and that's typically what we're gonna see in steroid use so if you've got a patient has pneumonia and you put them on steroids because they're having a COPD exacerbation because of pneumonia and the white cells go up but you don't see a left shift you don't see band Emia then you can probably chalk that up to steroids within reason right steroids are only gonna make the white blood cell go up you know maybe from 12 to 20 at most.

Okay if you start to see 30 40 50 then there's gonna be a problem speaking of which if we go back to infection on number one there is a very famous infection that I would be remiss in mentioning that we see in patients especially in the hospital and that the corollary is c-diff okay I don't want you to miss that if you start to see white counts in the 30 to 40 to 50 and higher range okay so these incredibly high white blood cells something you have to think about is Clostridium difficile colitis and in this situation, you typically do imaging like a CT scan to look at the bowel wall and you'll see thickening of the colonic wall in that situation typically the treatment includes Pio vancomycin, not IV vancomycin but Pio vancomycin and either Pio or IV Flagyl there are other treatments there are even surgical treatments so earlier.

You catch this the better so think about seed if you have a very very high white count, okay so we talked about certain types of infection we talked about steroids causing elevated white-blood-cell the other thing that can do this is if there is leukaemia, of course, remember with leukaemia and lymphomas there's a problem with the production or their survival of these white blood cells so, in other words, there is some sort of gene that gets turned on and these white blood cells start dividing rapidly and so you're making a lot of these and another potential reason why you could have leukaemia or lymphoma is if the cell doesn't die and doesn't involute and just hangs around so there are different variations on this, of course, you know that there is acute lymphocytic leukaemia there is chronic lymphocytic leukaemia there is acute myelogenous leukaemia which is a really bad player and then there's chronic myelogenous leukaemia.

That's the one with the Philadelphia chromosome etc so all of these can do it the thing that you must remember or one of the things that you should remember is something called lap or leukocyte alkaline phosphatase and this is the stuff inside the cells that are responsible for breaking down and killing bacteria well in cancer cells each cell has a lower amount of this leukocyte alkaline phosphatase so in the old days before we had flow cytometry and more genetic ways of figuring out whether or not there was leukaemia or lymphoma what they would do is check score okay and if there was a high leukocytosis but a low lap the score that was indicative of cancer leukaemia if the lab score was elevated that means that there was an appropriate amount of leukocyte alkaline phosphatase in these cells and that probably wasn't it so what should we look for again.

If it's lymphocytic leukaemia obviously we're gonna see elevated amounts of lymphocytes and so if you see a high white count and they're almost all lymphocytes think about this as a diagnosis if, on the other hand, you see various different types of myelogenous type of cells myelogenous meaning segmented neutrophils or eosinophils or monocytes things of that nature then that would be something along the lines of AML or even CML depending so these are divided okay what you really need is a peripheral smear and you need a pathologist to review the cells to see if they look atypical then you need to get even deeper and you might even need a bone marrow biopsy done to evaluate for that okay.

Then the last thing that we're going to talk about is a catastrophic event so a catastrophic event like myocardial infarction or a cardiac arrest or a massive pulmonary embolism is such a stress on the system or even surgery could be a stress on the system that this would cause a transient increase in the white count so what you would see is a bump up very quickly and then the white count would come back down again as you were to track it, okay there are many other things that can cause leukocytosis that I have not included here even a cold shower can make your white count go up so think about these things as you look at your WBC on your CBC thanks for joining us.

Wrist Ultrasound Exam

Wrist Ultrasound Exam

We are going to examine the wrist today, and the best transducer for this examination is the L25, the small footprint. We will check that the exam type is correct. We are doing an MSK type of exam. For orientation, there is a marker here, which corresponds to the turquoise dot on the screen. Keep this marker proximal when I am examining longitudinally and medial when I am examining transversally. We will start the wrist on the dorsal surface and examine transversally first. There are six compartments, beginning with the first compartment at the base of the thumb, and the sixth compartment near the ulnar styloid.

When we look at the wrist structures, we are looking at not only tendons and bones, but we are also looking at a multitude of joints. If I come over here to a middle portion, we are looking at carpal bones here. With the presence of synovitis, we would have hyperechoic or anechoic fluid and thickening of synovium at these recesses, which are the joints. None of that is present here. We will move over to the extensor tendons of the thumb, where you can sometimes see de Quervain's tenosynovitis, and here is a nice view of one of the long tendons of the thumb.

These extensor Digitorum tendons here are normal in an appearance on the cross-section. You see right over the distal end of the radius, which is right here these two thumb tendons. This then can be traced distally out toward the thumb, and these tendons and their Peritendinous tissue can be examined carefully. On the other side of the wrist toward the ulna, we have a very nice view of the extensor carpi Ulnaris tendon, which is one of the largest extensor tendons in the wrist and easiest to see. It also is frequently surrounded, in a patient with an inflammatory process, with fluid or synovium, and that can be seen as either anechoic or hyperechoic shadow around the distinct oval-shaped tendon, which is hyperechoic, and you can see the fibrillar nature within it. If we look longitudinally, keeping this dot proximal, and find that extensor carpi Ulnaris tendon, you can see these parallel lines, which are going from left to right.

There are areas that are hyper echo alternating with hypoechoic. This is a normal appearance of the tendon and visualizes Peritendonous tissue. The retinaculum, which is up here, in deep to this, this, is the distal part of the ulna. The first part of carpal bones and the triangular ligament is in here. Next, we look at the volar, or palmer surface of the wrist. Most of the time, we are going to be looking at the median nerve in this area. Again, the transducer marker is placed medially. This structure here is the median nerve. We can go toward the radial side and see the artery, the hyperechoic or anechoic area that has a small pulsation.

Sometimes checking colour Doppler signal or Doppler signal is helpful, and the median nerve, then, is seen right here in the middle. On the lunar surface, going in this direction is the ulnar artery, and we can freeze the image and take a measurement of the median nerve if it is desired to see whether this is enlarged using the direct correlation between this measurement and the presence of carpal tunnel syndrome. So I have placed my callipers on both sides of the median nerve, just inside the perineurium, and then I'm going to hit this ellipse button. Then I can actually take an approximate surface area. She has a .08 centimetre squared area, which is normal, and so by ultrasound criteria does not have carpal tunnel syndrome.

Scanning Technique - Ultrasound Foot Exam

Scanning Technique - Ultrasound Foot Exam

We are going to exam the ankle. She is lying down on her back with her knee flexed and ankle in approximately this position. I have selected an L25 transducer because it has a small footprint. It is easy to get around the curves in the ankle. On the SonoSite M-Turbo, I have set for its factory preset for Msk. For orientation, this mark on the transducer corresponds to the turquoise dot on the upper left portion of the screen. And I'll examine the anterior portion of the true ankle joint first. And on the left side of the screen is the tibia. And in this view, you see the tibiotalar joint.

There is a hypoechoic, or anechoic, stripe over the talus, which is cartilage. And there are vessels and tendons superficially. This would be one of the best views for a rheumatologist to find an ankle effusion. And that can be seen as an anechoic area in that V between the two bones. The lateral aspect of the ankle joint can also be examined. The fibula is the bony structure underneath the marker. And the talus is to the right. You can see an effusion again, between those bones as well. Transverse images are very good for looking at extensor tendons, and for tendon abnormalities. You might see anechoic fluid around the tendon or synovitis. And also see in the middle of the screen, the Dorsalis Pedis artery pulsating.

It is very important to identify the position of the arteries so that when you do injections, so you'll be able to avoid them. Next, I am going to examine the medial aspect of the ankle. The medial tendons, three of them, run just inside, or just posterior, to that medial malleolus. It is best to examine these initially in the transverse plane. And we can see two of those tendons very clearly, right superficial to the tibial bone. As a rheumatologist, you can see Peritendinous processes with fluid and synovial proliferation. You can also find large tears or tendinopathy. A longitudinal image of those tendons is also very easy to obtain because they're so superficial. We can look at the lateral aspect of the ankle.

The peroneus tendons are present here. And just posterior to the lateral malleolus are the peroneus tendons. You can see them on the screen just to the right of the bone. There are two tendons there. For examination of the Achilles tendon, it's best to have the patient in the prone position and have the Achilles tendon lined up. The image that you see on the screen, the bony structure is the calcaneus. The Achilles tendon is inserting into the calcaneus distally. This is a frequent zone of calcification. And then going proximally, you can get a very nice view both medially and laterally of this Achilles tendon. The structures deeper to the tendon include a bursa and some fatty tissue. This is the area where many tendon tears occur.

We also should then examine the Achilles tendon transversely. And this can be done all the way distal, to the point where this Achilles tendon gets smaller and smaller, and inserts on the bone. Or as we move proximally, you might be able to see areas of tendinosis, or tendonitis, or rupture here. There are a number of appropriate measurements that are frequently taken for the size, accessing the size of the Achilles tendon. These can be done both in the transverse and longitudinal plane. And usually, we go just to the border where the calcaneus ends and freeze the image.

Then using the callipers, and place one on this side and one on this site for getting a measurement from medial to lateral. You can then get another measurement of thickness from the superficial to the deep. You can also measure an area. Probably the best way to do it is manual. And so then this gives us an area of the tendon, in a cross-section, and that area is .85 centimetres squared. You can also take measurements of the Achilles tendon in the longitudinal plane. And measure the thickness at the edge of the calcaneus.