CT of abdomen with contrast ( Fig. 3.2, A, B )

A, CT showing multiple pyogenic abscesses in the liver. B, Computed tomography scan demonstrates a low-attenuation mass in the right lobe of the liver with a prominent halo.

A, Courtesy Dr. Mukesh Harisinghani, Boston; B, From Kuhn JP, Slovis TL, Haller JO: Caffey’s pediatric diagnostic imaging , vol 2, ed 10, Philadelphia, Mosby, 2004, p. 1473.

Ultrasound of abdomen is useful in young women and children

Gram stain and C&S of abscess

CBC count with differential

Blood culture × 2

ALT, AST

BUN, creatinine, glucose

Ultrasound of abdominal aorta ( Fig. 3.4 ) is best initial screening test; CT is more accurate test

Ultrasound appearance of an abdominal aortic aneurysm, seen in cross section. Sonography is highly accurate in diagnosing and measuring infrarenal aortic aneurysms.

Courtesy M. Ellis.

CT of abdominal aorta with IV contrast for preoperative imaging and size estimation, and to diagnose perforation/tear

Angiography for detailed arterial anatomy before surgery

None

Serum creatinine level before IV contrast

Barium swallow with fluoroscopy ( Figs. 3.6, 3.7 )

Achalasia. GEJ, Gastroesophageal junction.

From Weissleder R, Wittenberg J, Harisinghani MG, Chen JW: Primer of diagnostic imaging , ed 5, St. Louis, Mosby, 2011.

Radiograph of esophageal achalasia showing the typical tapered (“bird beaked”) appearance at the cardioesophageal junction and retention of food and fluid within a dilated and adynamic esophagus.

From Talley NJ, Martin CJ: Clinical gastroenterology , ed 2, Sidney, Churchill Livingstone, 2006.

Esophageal manometry to confirm diagnosis. It reveals esophageal aperistalsis and abnormal relaxation of lower esophageal sphincter.

Upper endoscopy to exclude mechanical obstruction of the esophagus in the region of the lower sphincter

None

CBC

Serum albumin for nutritional assessment

None

Chest x-ray

ABGs

Serum electrolytes

Urine electrolytes

Renal ultrasound

Chest radiograph (r/o pleural effusion, pulmonary/renal syndromes [e.g., Goodpasture, granulomatosis with polyangiitis])

CT scan of kidneys without contrast (r/o suspected obstruction)

Urinalysis

Serum osmolality, urine osmolality, urine creatinine

Serum electrolytes, calcium, phosphate, uric acid, magnesium

Calculate FENa = [UNa/PNa/Ucreat/Pcreat × 100]; FEna <1 in prerenal, >2 in intrinsic renal failure

None

CT or MRI of adrenals with contrast

Chest x-ray

IV cosyntropin test, basal cortisol and serial measurement of cortisol, ACTH level

Serum electrolytes (hyponatremia, hyperkalemia)

FBS, BUN, creatinine

CBC (anemia)

MRI of adrenal gland with contrast

CT of adrenal gland with and without contrast ( Fig. 3.13 ) if MRI is contraindicated

Adrenal adenoma. On a computed tomography scan, incidental note was made of a small (approximately 1 cm) left adrenal mass ( arrows ). This small size combined with a relatively low-density (dark) center is consistent with a benign adrenal adenoma. Note that any adrenal mass larger than several centimeters should be suggestive of malignancy.

From Mettler FA: Essentials of radiology , ed 3, Philadelphia, Saunders, 2014.

Serum electrolytes

If symptoms of pheochromocytoma, obtain plasma-free metanephrine level, 24-hour urine collection for metanephrines

If cushingoid appearance, obtain overnight dexamethasone suppression test

If signs of virilization or feminization, order 24-hour urine for 17-ketosteroids and plasma DHEAS

If hypertension is present with associated hypokalemia, evaluate for aldosteronism

CT of liver

Ultrasound of liver

Bone scintigraphy (nuclear bone scan) if Paget’s disease of bone is suspected

Plain x-rays of abnormal areas identified on bone scan to exclude metastatic disease and confirm Paget’s disease

GGT

Serum calcium, phosphate

ALT, AST

CT of liver

Ultrasound of liver

None

Ferritin/transferrin saturation

Viral hepatitis serology

GGT, alkaline phosphatase, bilirubin

AMA, ASMA, ANA

MRI of pituitary/hypothalamus with gadolinium when hypothalamic/pituitary lesion is suspected

Pelvic ultrasound

Serum hCG

FSH

Prolactin

TSH

Progesterone challenge test if initial labs are normal. Test will differentiate between estrogen-deficient state (no bleeding) and estrogen-sufficient state (withdrawal bleeding).

Karyotype (r/o Turner syndrome) in patients with primary ovarian insufficiency

MRI of pituitary/hypothalamus with gadolinium when hypothalamic/pituitary lesion is suspected

Pelvic ultrasound

CT or MRI of adrenals

Serum hCG

Prolactin

FSH

Progesterone challenge test to differentiate between estrogen-deficient state (no bleeding) and estrogen-sufficient state (withdrawal bleeding)

LH

Testosterone, DHEAS

TSH

None

None

Reticulocyte count

Serum B ₁₂ level, RBC folate level

ALT, AST, GGTP

TSH

Direct and indirect antiglobulin test

Stool for OB

Bone marrow examination

None

None

Reticulocyte count

Stool for occult blood test × 3

Ferritin level

TIBC, serum iron

Hemoglobin electrophoresis

Serum lead level

None

None

ANA pattern evaluation

Anti-Ds DNA Ab

Anti-Smith Ab

Anti-RNP Ab

Anti-SS-A, Anti-SS-B

ESR

CBC

CT (sensitivity 83%–100%); CT of aorta ( Fig. 3.22 ) is generally readily available and performed as the initial diagnostic modality in suspected aortic dissection

Computed tomography scan demonstrating the true lumen and false lumen.

From Marx JA, Hockberger R, Walls R: Rosen’s emergency medicine , ed 7, Philadelphia, Mosby, 2010.

MRI (sensitivity 90%–100%); difficult test for unstable, intubated patient

TEE (sensitivity 97%–100%); can also detect aortic insufficiency and pericardial effusion

Aortography (sensitivity 80%–90%); involves IV contrast; allows visualization of coronary arteries

Chest radiograph ( Fig. 3.23 ), ECG

Chest radiograph in acute type A aortic dissection demonstrating a widened mediastinum and enlargement of the ascending and descending aortic shadows ( arrows ).

From Bonow RO, Mann DL, Zipes DP, et al: Braunwald’s heart disease , ed 9, Philadelphia, Saunders, 2012.

None

CBC

BUN, creatinine

CT of appendix ( Fig. 3.26, B ) with oral and IV contrast

Appendicitis. A, Ultrasound shows a thickened hypoechoic tubular blind-ended structure in the right iliac fossa. The surrounding fat is hyperechoic. B, Computed tomography shows the thickened, inflamed appendix ( arrow ).

Courtesy Dr. A McLean, St. Bartholomew’s Hospital, London. From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and Allison’s diagnostic radiology , ed 4, Philadelphia, Churchill Livingstone, 2001.

Ultrasound of pelvis (see Fig. 3.26, A ) may be used instead of CT in children and women of reproductive age when CT is unavailable or contraindicated

CBC with differential

Urinalysis

Serum pregnancy test in women of reproductive age

Ultrasound of abdomen/pelvis ( Fig. 3.28 ) is best initial diagnostic test

Ascites, ultrasound. Ultrasound is useful for detection of ascites. Simple fluids such as ascites are excellent sound transmission media, reflecting almost no sound waves. As a consequence, they appear quite hypoechoic (black) on ultrasound. This view of the right lower quadrant shows loops of bowel surrounded by fluid. During the ultrasound, the bowel loops would be seen to undergo peristalsis and drift back and forth in the ascitic fluid with patient movement. Ultrasound cannot distinguish the composition of the fluid—ascites, liquid blood, liquid bile, urine, and infectious fluids have a similar appearance, with a few exceptions. Blood may coagulate and form septations within the fluid collection. Infectious fluids also frequently form loculated fluid collections that may be recognized on ultrasound, although the exact composition cannot be determined.

From Broder JS: Diagnostic imaging for the emergency physician , Philadelphia, Saunders, 2011.

CT of abdomen/pelvis

Calculation of serum-ascites albumin gradient (SAAG) ( Table 3.2 ); analysis of paracentesis fluid for LDH, glucose, albumin, total protein

Paracentesis fluid analysis for cell count and differential, Gram stain, AFB stain, bacterial and fungal cultures, amylase ( Table 3.3 )

CBC, ALT, AST, BUN, creatinine

MRI of affected joint ( Fig. 3.30, A )

Aseptic necrosis of the hip in a renal transplant recipient. A, Early changes consisting of low-intensity oblique lines are noted by magnetic resonance imaging. B, Late changes of avascular necrosis by radiograph show narrowing of the hip joint space, sclerosis of the femoral head, and flattening of the left femoral head.

From Johnson RJ, Feehally J: Comprehensive clinical nephrology , ed 2, St. Louis, Mosby, 2000.

Bone scan if MRI is contraindicated or not readily available

Plain films of affected joint usually insensitive in early course but more evident as disease progresses ( Fig. 3.30, B )

None

CBC with differential

ESR (nonspecific)

ANA

MRI of LS spine

Plain radiographs of spine

CT scan of LS spine if MRI is contraindicated

Ultrasound or CT of abdominal aorta if AAA is suspected

None

CBC

ESR

Urinalysis

None

Ultrasound of abdomen

CT of abdomen

ERCP

MRCP

Bilirubin fractionation

Alkaline phosphatase

ALT, AST, PT (INR)

CBC

Antiglobulin test, haptoglobin

Viral hepatitis panel

ANA

LDH

None

None

PT (INR), PTT

Platelet count

Clot stability test

TT

Factor VIII, IX assay

PFA 100 assay

Fibrinogen level

Factor II, V, X, XIII

MRI of brain with contrast

CT scan with IV contrast ( Fig. 3.35 ) if MRI is contraindicated

Computed tomography (CT) with contrast. A, Note the large, wall-enhancing abscess in the left frontal lobe causing a shift of the brain to the right. B, The patient had no neurologic signs until just before the CT scan because the abscess is located in the frontal lobe, a “silent” area of the brain.

Kliegman RM, Stanton B, St. Geme J, et al: Nelson textbook of pediatrics , ed 19, Philadelphia, Saunders, 2011.

Echocardiography if bacterial endocarditis is suspected source of septic emboli to brain

CBC with differential

Blood cultures (10% positive)

ESR

Diagnostic mammogram ( Fig. 3.38, A )

Mammogram and ultrasound findings of breast disease. A, A stellate mass in the breast. The combination of a density with spiculated borders and distortion of surrounding breast architecture suggests a malignancy. B, Clustered microcalcifications. Fine, pleomorphic, and linear calcifications that cluster together suggest the diagnosis of ductal carcinoma in situ. C, An ultrasound image of breast cancer. The mass is solid, containing internal echoes and displaying an irregular border. Most malignant lesions are taller than they are wide.

From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston textbook of surgery , ed 17, Philadelphia, Saunders, 2004.

Breast ultrasound ( Fig. 3.38, B )

MRI of breast in selected cases (e.g., prior breast cancer, breast implant)

Breast biopsy of suspicious lesion ( Fig. 3.37 )

An ultrasound image shows a nonpalpable superficial breast mass (A). A second image shows the linear echogenic biopsy needle penetrating the mass (B).

From Mettler FA: Essentials of radiology , ed 3, Philadelphia, Saunders, 2014.

Aspiration and cytologic examination of breast cyst

Radionuclide iodine-113–labeled somatostatin scan (123-ISS) (octreotide scan) ( Fig. 3.40 )

Octreoscan illustrating uptake pattern in liver metastases from a small-bowel carcinoid.

From Cameron JL, Cameron AM: Small-bowel carcinoid/neuroendocrine tumors, Current surgical therapy , ed 10, Philadelphia, Saunders, 2011.

CT scan of abdomen, pelvis, and chest with oral and IV contrast to localize tumor and detect metastases

Echocardiogram or cardiac MRI in suspected cardiac carcinoid

24-hour urine for HIAA

ALT, AST

Serum electrolytes, BUN, creatinine

Alkaline phosphatase

Endoscopic biopsy of gastric carcinoids

Echocardiogram ( Fig. 3.42 )

Echocardiogram shows a large pericardial effusion ( arrows ). D, Diaphragmatic pericardium; V, ventricle.

From Sellke FW, del Nido PJ, Swanson SJ: Sabiston & Spencer surgery of the chest , ed 9, Philadelphia, Elsevier, 2016.

Cardiac MRI if pericardial thickening or mass

ECG

None

TSH

Creatinine, ALT

ESR

Urinalysis

Ultrasound of abdomen is preferred initial screening test; allows visualization of gallbladder and bile ducts to differentiate extrahepatic obstruction from intrahepatic cholestasis; insensitive but specific for visualization of common duct stones

CT of abdomen ( Fig. 3.45 ) is less accurate for gallstones but more sensitive than ultrasound for visualization of bilirubin distal part of common bile duct; also allows better definition of neoplasm

Ascending cholangitis, dilated bile ducts, computed tomography with intravenous contrast. Obstruction of the biliary ducts can lead to devastating ascending infection—cholangitis. This is largely a clinical diagnosis, because classic imaging findings such as pneumobilia can lag behind clinical deterioration. Fever, jaundice, abdominal pain, and altered mental status should prompt immediate antibiotic therapy and surgical consultation, regardless of imaging findings. A, C, Axial images. B, D, Close-ups from A and C, respectively. This patient with a known pancreatic mass and a previously placed biliary stent presented with right upper quadrant abdominal pain. She became febrile during her emergency department stay. Her scan shows biliary ductal dilatation, suggesting obstruction of her stent. In addition to antibiotic therapy, a procedure to relieve obstruction is needed. Her blood cultures subsequently grew Escherichia coli , consistent with ascending cholangitis.

From Broder JS: Diagnostic imaging for the emergency physician , Philadelphia, Saunders, 2011.

MRCP or ERCP indicated if CT or ultrasound is inconclusive; MRCP can be used to visualize common bile duct and level of obstruction; ERCP can also be used to confirm obstruction and its level; it also allows collection of specimen for culture and cytologic examination and provides relief of obstruction

CBC with differential

Blood culture × 2

Serum amylase, lipase

ALT, AST, alkaline phosphatase

Ultrasound of gallbladder ( Fig. 3.47 )

Acute calculous cholecystitis. A, Gallstone with posterior shadowing and anterior wall thickening (measured to be 9.1 mm with the calipers; stars indicate the ends of the calipers measuring the gallbladder wall). B, Acute cholecystitis with pericholecystic fluid ( arrow ). A gallstone was impacted in the gallbladder neck.

From Adams JG et al: Emergency medicine: clinical essentials , ed 2, Philadelphia, Elsevier, 2013.

Nuclear imaging (HIDA) scan ( Fig. 3.48 ) is useful for suspected acalculous cholecystitis or when ultrasound is inconclusive

Acute cholecystitis. Following the intravenous administration of 200 MBq (5 mCi) of Tc-99m–HIDA and a stimulus of cholecystokinin, the region of the liver and gallbladder is imaged. Intrahepatic bile ducts are visualized, as is excretion through the common duct into the small bowel. The gallbladder is not seen. This patient had gallstones demonstrated by ultrasound and confirmed at surgery. The pathologic diagnosis was acute cholecystitis.

From Grainger RG, Allison DJ, Adam A, Dixon AK [eds]: Grainger and Allison’s diagnostic radiology , ed 4, Philadelphia, Churchill Livingstone, 2001.

CT of abdomen useful in suspected abscess, neoplasm, or pancreatitis

CBC with differential

Alkaline phosphatase

ALT, AST, bilirubin

Serum amylase

Ultrasound of gallbladder ( Fig. 3.50 ) will detect stones and biliary sludge (sensitivity 95%, specificity 90%)

Examples of cholelithiasis (A to D) depicting the different appearances of gallstones ( arrows ).

From Adams JG et al: Emergency medicine: clinical essentials , ed 2, Philadelphia, Elsevier, 2013.

CT of abdomen useful in patients with inconclusive ultrasound to r/o neoplasm or abscess mimicking cholelithiasis; however, it is less sensitive than ultrasound for cholelithiasis

None

Lipid panel

ALT, alkaline phosphatase, bilirubin

CBC, amylase

None

Three-phase radionuclide bone scan ( Fig. 3.52 )

Reflex sympathetic dystrophy in a patient with a history of right wrist fracture. Three-phase bone scintography shows increased tracer delivery to the right distal upper extremity diffusely (arrow) on flow (top) and blood pool (middle) images. Delayed images (bottom) reveal diffuse abnormal uptake in the wrist (lower arrow) and increased activity in a juxtaarticular distribution (upper arrows) .

From DeLee D, Drez D: DeLee and Drez’s orthropaedic sports medicine , 2 ed. Philadelphia, 2003, Saunders.

Radiograph of affected limb (r/o other cause of patient’s symptoms)

None

CBC, ESR

ANA

FBS

CT colonography if patient refuses colonoscopy

Consider barium enema (if patient refuses colonoscopy or CT colonography)

Pelvic ultrasound

GI motility study

None

CBC

TSH

Serum calcium, electrolytes, BUN, creatinine, ALT

None

None

CPK fractionation

Serum troponin levels

CBC, electrolytes, BUN, ALT, creatinine

TSH, urinalysis

ANA

ESR, CRP

MRI or CT of adrenals with IV contrast in suspected adrenal Cushing’s syndrome

MRI of brain ( Fig. 3.55 ) with gadolinium in suspected pituitary Cushing’s syndrome

A, Magnetic resonance imaging (MRI) scan of pituitary demonstrates the typical appearance of a pituitary microadenoma. A hypodense lesion is seen in the right side of the gland ( arrow ), with deviation of the pituitary stalk away from the lesion. After a biochemical diagnosis of Cushing’s disease, this patient was cured by transsphenoidal hypophysectomy. B, MRI scan of the pituitary gland demonstrates a large macroadenoma ( arrow ) in a patient with Cushing’s disease. In contrast to smaller tumors, large macroadenomas are invariably invasive and recur after surgery.

From Melmed S, Polonsky K, Larsen P, Kronenberg H: Williams textbook of endocrinology , ed 12, Philadelphia, Saunders, 2011.

CT of chest in patients with ectopic ACTH production to r/o neoplasm of lung, kidney, or pancreas

24-h urine-free cortisol (gold standard for diagnosis, a 3-fold to 4-fold increase above normal confirms diagnosis)

Overnight dexamethasone suppression test

Plasma cortisol

Late-night salivary cortisol measurement

Electrolytes, creatinine, glucose

CRH plus desmopressin stimulation test

Compressive duplex ultrasonography of affected extremity ( Fig. 3.58 )

Doppler ultrasound appearance of deep vein thrombosis. The superficial femoral vein is filled with echogenic material representing thrombus, and no flow can be identified in the vein on Doppler evaluation. Flow can be identified in the adjacent artery on color Doppler evaluation ( arrows ).

From Crawford MH, DiMarco JP, Paulus WJ [eds]: Cardiology , ed 2, St. Louis, Mosby, 2004.

Contrast venography; “gold standard” but invasive and painful

MRDTI; very accurate and noninvasive but limited by cost and availability

d -dimer assay by ELISA

PT, PTT, platelet count

Coagulopathy workup (e.g., protein C, protein S, antithrombin III, factor V Leiden, lupus anticoagulant) in patients with suspected coagulopathy

None

MRI of pituitary with gadolinium

Pelvic ultrasound (females)

Bone age (hand and wrist film)

FSH, LH

Prolactin

Serum free testosterone

GnRH

Chromosomal karyotyping

IGF-1

CT of head without contrast to r/o subdural hematoma, hemorrhage in patients with focal neurologic deficits on examination

Chest x-ray (rule out pneumonia)

Variable with clinical suspicion and physical examination (e.g., toxicologic screen in suspected drug abuse, CSF examination in suspected encephalitis or meningitis, CBC with differential, urinalysis, urine culture in suspected infectious process)

Blood culture × 2

ALT, AST

TSH, B ₁₂ level

BUN, creatinine, urinalysis

ABGs or pulse oximetry

Serum electrolytes, glucose, calcium, phosphate, magnesium

None

Small-bowel series if malabsorption is suspected

Capsule endoscopy

Serum electrolytes, BUN, creatinine

Stool Na ⁺ , K ⁺

CBC with differential

Stool for Clostridium difficile toxin assay

Stool for O&P

Stool for occult blood × 3

Stool Sudan stain (in malabsorption, mucosal disease, pancreatic insufficiency, bile salt insufficiency)

Stool osmolality (stool [Na plus K]) × 2

ALT, AST

TSH, free T ₄

IgA anti-tTG antibody to screen for celiac disease

Albumin, total protein, glucose

Stool cultures for Escherichia coli, Shigella, Salmonella, Yersinia, Campylobacter, Entamoeba histolytica

Antigliadin IgA antibody, endomysial IgA antibody

Colon biopsy

None

Chest radiograph to exclude infectious process in patients presenting with pulmonary symptoms

PT (INR), PTT, fibrin degradation products (FDPs), d -dimer, TT

Fibrinogen level, platelet count

CBC, peripheral blood smear

ALT, AST to r/o liver disease

Factor V, VIII

CT scan of abdomen and pelvis with oral and IV contrast ( Fig. 3.64 ); typical findings are thickening of bowel wall, pericolonic fat stranding, abscess formation

Axial and coronal postcontrast images show a redundant sigmoid looping to the right with thick wall and pericolonic fat stranding ( arrow ) suggestive of diverticulitis.

From Fielding JR, Brown DL, Thurmond AS: Gynecologic imaging , Philadelphia, Saunders, 2011.

None

CBC with differential

Blood culture × 2

Urinalysis, urine culture

ALT, creatinine, BUN, electrolytes, amylase

Serum pregnancy test in reproductive-age women

Endoscopy

UGI series if patient refuses endoscopy

Chest radiograph

Ultrasound of neck

H. pylori stool antigen or breath test

CBC

Chest radiograph

ECG

Echocardiogram

PFTs

CT of chest to rule out pulmonary embolism

CBC (r/o anemia, infection)

d -dimer

ABGs or pulse oximetry (r/o PE)

TSH

Serum electrolytes, BUN, creatinine

BNP

None

Pelvic ultrasound

Urinalysis, urine C&S ( Box 3.2 )

PCR assay for Chlamydiae or Neisseria gonorrhoeae

summarizes patients in which urine culture is indicated

VDRL, HIV

Gram stain and C&S of urethral discharge

Transvaginal ultrasound ( Fig. 3.69 )

Ultrasound scan showing ectopic pregnancy. A, Transabdominal scan showing empty uterus with a complex mass in the right adnexa measuring 21 × 22 mm. B, Transvaginal scan showing absence of gestational sac in the uterus and decidual reaction with marked endometrial thickening. There is free fluid in the pouch of Douglas (blood will be found there in ruptured ectopic pregnancy).

From Greer IA, Cameron IT, Kitchener HC, Prentice A: Mosby’s color atlas and text of obstetrics and gynecology , London, Harcourt, 2000.

CT of abdomen and pelvis with IV contrast ( Fig. 3.70 ) in ruptured ectopic pregnancy with confirmed fetal loss

Ruptured ectopic pregnancy: computed tomography (CT) with intravenous and oral contrast viewed on soft-tissue windows. This 20-year-old woman underwent abdominal CT for suspected appendicitis, given a history of right lower abdominal pain. A urine pregnancy test was not obtained before CT scan. A and B, Free fluid representing hemoperitoneum is seen in the pelvis and extending to a perihepatic subdiaphragmatic location (compare this dark fluid density with the urine-filled bladder). A ringlike enhancing structure is seen in the right pelvis. A bright blush of contrast is seen that is not contained within vessels or bowel—this represents active bleeding from a ruptured ectopic pregnancy. It is bright because of active extravasation of contrast, whereas blood that accumulated before contrast injection is dark. At laparotomy, 2 L of hemoperitoneum were evacuated, and active bleeding from the right fallopian tube was noted. A 4-cm structure that looked like a gestational sac with a possible tiny embryo within it was also found free in the abdomen.

From Broder JS: Diagnostic imaging for the emergency physician , Philadelphia, Saunders, 2011.

Serum hCG (quantitative)

Serum progesterone (decreased production in ectopic pregnancy)

CBC

Urinalysis

Doppler ultrasound in suspected DVT

Plain x-ray films of extremities in patients with history of musculoskeletal trauma (r/o fracture)

Echocardiogram (r/o CHF, valvulopathy)

CT and/or ultrasound of pelvis

None

d -dimer by ELISA when DVT is suspected

Creatinine, ALT, albumin

TSH

Urinalysis

24-hour urine protein to r/o nephrotic syndrome if urinalysis reveals proteinuria

BNP

Box 3.3 summarizes causes of lower- extremity edema

Transesophageal echocardiogram (TEE), ( Fig. 3.73 )

A transesophageal 120-degree view in a patient with prosthetic aortic valve endocarditis and aortic root abscess. The posterior aortic root wall is thickened with lucent areas of liquefaction (abscess formation) from infection within the wall ( arrowheads ). The infection can extend down the intervalvular fibrosa to involve the anterior mitral valve leaflet ( AMVL ). Multiple small echo densities are attached to the prosthetic aortic valve ( PAV ) sewing ring, which are representative of prosthetic valve vegetations. LV , Left ventricle.

From Boxt LM, Abbara S: The requisites: cardiac imaging , ed 4, Philadelphia, Elsevier, 2016.

Transthoracic echocardiography if TEE is not readily available or patient is uncooperative

Blood culture × 3

CBC with differential

ESR (nonspecific)

Urinalysis