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  • 1. NMSCR 1/30/2015 AMSER National Medical Student Curriculum in Radiology Edited by: Kitt Shaffer M.D. Petra Lewis M.D. 1
  • 2. NMSCR 1/30/2015 Table of Contents Table of Contents...........................................................................................................................................................................2 Key Concepts..................................................................................................................................................................................5 Curricular Framework..................................................................................................................................................................7 1. Core radiology topics...................................................................................................................................................................7 2. Detailed organ-based curriculae................................................................................................................................................7 3. Curriculum resources.................................................................................................................................................................8 4. Diagnostic short-list....................................................................................................................................................................8 Core Topics.....................................................................................................................................................................................9 1. Physics concepts important to the clinician...............................................................................................................................9 2. Orientation to radiology department (specific to individual programs)..................................................................................10 3. Use of PACS system (specific to individual programs)...........................................................................................................10 4. Radiation safety and risks ........................................................................................................................................................10 5. Imaging in pregnancy and breast feeding...............................................................................................................................11 6. Other ‘risks’ of radiology..........................................................................................................................................................12 7. Financial costs..........................................................................................................................................................................13 Chest Imaging..............................................................................................................................................................................14 1. Technical aspects......................................................................................................................................................................14 2. Normal anatomy........................................................................................................................................................................14 3. Pathological conditions.............................................................................................................................................................15 4. Invasive procedures...................................................................................................................................................................17 5. Imaging algorithms (appropriateness criteria)........................................................................................................................17 Abdominal Imaging.....................................................................................................................................................................19 1. Technical aspects......................................................................................................................................................................19 2. Normal anatomy........................................................................................................................................................................19 3. Pathological conditions.............................................................................................................................................................20 4. Invasive procedures...................................................................................................................................................................21 5. Imaging management (appropriateness criteria)....................................................................................................................21 Musculoskeletal Radiology..........................................................................................................................................................22 1. Technical aspects......................................................................................................................................................................22 2. Normal anatomy........................................................................................................................................................................22 3. Pathological conditions.............................................................................................................................................................23 4. Invasive procedures...................................................................................................................................................................24 5. Imaging algorithms (appropriateness criteria)........................................................................................................................24 Interventional Radiology.............................................................................................................................................................26 1. Technical aspects......................................................................................................................................................................26 2
  • 3. NMSCR 1/30/2015 2. Normal anatomy........................................................................................................................................................................26 3. Pathological conditions.............................................................................................................................................................27 4. Invasive procedures...................................................................................................................................................................27 5. Imaging algorithms (appropriateness criteria)........................................................................................................................28 Emergency Radiology..................................................................................................................................................................29 1. Technical aspects......................................................................................................................................................................29 2. Normal anatomy........................................................................................................................................................................29 3. Pathological conditions.............................................................................................................................................................29 4. Invasive procedures...................................................................................................................................................................32 5. Imaging algorithms (appropriateness criteria) and cost effective imaging............................................................................32 Women’s Imaging........................................................................................................................................................................33 1. Technical aspects......................................................................................................................................................................33 2. Normal anatomy........................................................................................................................................................................34 3. Pathological conditions.............................................................................................................................................................34 4. Invasive procedures...................................................................................................................................................................35 5. Imaging algorithms (appropriateness criteria)........................................................................................................................35 Neuroimaging...............................................................................................................................................................................38 1. Technical aspects......................................................................................................................................................................38 2. Normal anatomy........................................................................................................................................................................38 3. Pathological conditions.............................................................................................................................................................38 4. Invasive procedures...................................................................................................................................................................39 5. Imaging algoritms (appropriateness criteria)..........................................................................................................................40 Nuclear Medicine.........................................................................................................................................................................41 1. Technical aspects......................................................................................................................................................................41 2. Normal anatomy........................................................................................................................................................................41 3. Pathological conditions.............................................................................................................................................................41 4. Invasive procedures...................................................................................................................................................................42 5. Imaging algorithms (appropriateness criteria)........................................................................................................................42 Pediatrics......................................................................................................................................................................................44 1. Technical aspects......................................................................................................................................................................44 2. Normal anatomy........................................................................................................................................................................44 3. Pathological conditions.............................................................................................................................................................45 4. Invasive procedures...................................................................................................................................................................45 5. Imaging algorithms (appropriateness criteria)........................................................................................................................46 Curriculum Resources.................................................................................................................................................................47 1. Teaching Methods.....................................................................................................................................................................47 2. Websites.....................................................................................................................................................................................49 3
  • 4. NMSCR 1/30/2015 3. CDROM based programs..........................................................................................................................................................51 4. Textbooks...................................................................................................................................................................................52 Diagnostic Shortlist : The “Must See” Images...........................................................................................................................53 4
  • 5. NMSCR 1/30/2015 Key Concepts This document is not intended to serve as a definitive list of all material that should be included in every radiology clerkship. Because of the wide range of variation between schools in the way radiology is taught, each individual school will likely have unique needs in terms of material to be covered. This document was written to be as inclusive as possible, and should serve as a starting point for a clerkship director looking for opportunities of expanding their course. The material listed in each area is more than could realistically be covered in a single month or less. It is hoped that most of the core or essential material in each section will be covered at some point in the four years of medical school, but not necessarily during a dedicated radiology clerkship. In particular, the section on core topics and curricular resources is intended to expand the horizons of educators and to offer new methods or sources of information that they may want to add to existing clerkships. This document is thus intended as an overarching compendium of possible topics and resources from which educators can pick and choose those portions that best suit their needs. Aim: These could be used as guidelines for those programs that wish to develop their own curriculum. Outline: Philosophy behind a student rather than resident based curriculum in Radiology. These students will be our clinical colleagues. What do we want the internist utilizing radiology for the care or his or her patients to know about the practice of radiology and how can we teach it in the time we have available? General concepts about the medical student curriculum in radiology (all areas): • This should not be a “watered down” radiology resident curriculum. • It should be a realistic curriculum – most students spend no more than 4 weeks in radiology. • It should include radiological topics that will be covered while on clinical services as well as on dedicated radiology rotations. • It should aim at those skills that are required by students entering general medicine or surgery rather than students entering radiology. • It should be flexible enough to be incorporated into a variety of different program formats • It should identify for students critical areas to focus on during their rotations It should include the following general areas: • Exposure to the scope of radiology • Imaging management skills – appropriate image ordering – cost effective, evidence based medicine, tailoring studies to patient and case specifics • Management of negative or equivocal imaging • Concepts of positive and negative predictive values of imaging methods • Knowledge of how procedures and imaging are performed (i.e. see imaging performed not just images) • Image interpretation: Should focus on plain films and to lesser extent CT Should focus on emergency radiology and common conditions • Use of PACS • Utility of image guided procedures • Access to radiology ordering and reporting systems • The risks of medical imaging (e.g. radiation induced cancer, incidental findings requiring additional evaluation) • Clinician-radiology interactions Consultations Importance of providing clinical information 5
  • 6. NMSCR 1/30/2015 6
  • 7. NMSCR 1/30/2015 Curricular Framework 1. Core radiology topics Aim: This curriculum covers topics common to several imaging modalities and organ systems to avoid repetition. Topics could be covered separately or integrated into specialist areas. Outline: Physics concepts important to clinicians Densities, silhouette signs Terminology used in radiology Key modality comparisons, advantages and limitations (modality and patient specific) Use of contrast media, types, advantages Orientation to radiology department Ordering urgent/routine studies Getting wet readings, accessing reports Use of PACS system Radiation safety Risks associated with radiation exposure CXR equivalents of common examinations Pediatric exposure Imaging in pregnancy Other complications of radiology Contrast media (complications, high risk groups, prophylaxis) Interventional procedures MRI Societal and emotional impact Comparative modality costs 2. Detailed organ-based curriculae Aim: To provide more details of the topics that ideally should be covered during a 4-week elective, or incorporated into a integrated radiology curriculum. These utilize a common structured format and will be outlines rather than text-book replacements. These also contain suggestions for students who may be undertaking a speciality-dedicated radiology elective. Outline: Curriculae developed: Chest Musculoskeletal Neuroimaging Pediatrics Woman’s imaging Abdominal Nuclear Medicine Emergency Radiology Interventional Radiology Curricular topics: Technical aspects Techniques used to image this anatomical/physiological area 7
  • 8. NMSCR 1/30/2015 Patient preparation and education Studies that should be visualized during elective Normal anatomy Structures that should be identified on common modalities Emphasis on cross-modality correlation Pathological conditions Common pathological conditions/findings that the student should recognize Iatrogenic pathology Emergency “don’t miss” findings Diagnostic situations/conditions that do NOT require imaging Invasive procedures Identify clinical scenarios where image-guided procedures are beneficial Imaging algorithms (appropriateness criteria) Appropriate imaging management algorithms for common diagnostic situations Cost-effective imaging Incorporating pre-test probabilities 3. Curriculum resources Aim: To provide guidance on how the curriculum may be incorporated into various program formats, with suggestions for teaching methods and educational resources. Outline: Teaching methods: Group based conferences Student presentations One-on-one teaching Informal quizzes Formal exams Games Self-learning exercises Practical experience Websites Casefiles Tutorials General information and portals CDROM based programs Textbooks 4. Diagnostic short-list Aim: To provide a limited list of diagnoses that all students must be able to recognize. This should be covered during the radiology course, but could be used as a basis for a quiz, game or other format. Outline: 30-40 common diagnoses with an emphasis on ‘don’t miss’ or emergency findings covering all organ systems. Mostly plain films, some CT.. These images could be collated by AMSER as a shared resource. 8
  • 9. NMSCR 1/30/2015 Core Topics 1. Physics concepts important to the clinician 1.1. What produces density differences on radiographs 1.2. Terminology used in radiology (reports) Plain films/fluoroscopy: Lucency, opacity, interstitial, reticular, linear, nodule, mass, atelectasis, alveolar (incorrect terms inc. lung field, infiltrate) CT: Attenuation, enhancement, density, Hounsfield units Ultrasound: Hyper and hypoechoic, attenuation MRI: Increased and decreased signal Nuclear medicine Hot spots, cold spots, radiotracer, radioisotope 1.3. Silhouette signs on CXR/KUB 1.4. Key modality differences Anatomical resolution versus soft tissue contrast Fluoroscopy: Concept of dynamic imaging with Xrays and contrast CT : Concept of tomography, high resolution, fast, best anatomic resolution, CTA, CT fluoroscopy, multiplanar through reconstruction Ultrasound: Concepts of sound reflection as imaging agent, portable scanner, multiplanar MRI: Concepts of magnetic resonance, multiplanar imaging, best soft tissue resolution, limited access to patient in scanner, details of physics beyond student level Nuclear medicine: Concept of anatomical versus physiological imaging, internal administration of radioisotopes 1.5. Limitations of modalities Obese patients (weight limits, ultrasound) Acoustic windows in ultrasound (lung, bowel gas) Claustrophobia (MRI>CT and PET) Immobile/elderly/sick patients (MRI, fluoro) CT and MRI may require sedation esp. in children 1.6. Contrast media Types of contrast media Intracavitary: Bowel Rationale Types (barium, water soluble, gastrograffin) 9
  • 10. NMSCR 1/30/2015 Double contrast versus single contrast Use of water soluble agents versus barium GI studies Benefits of oral contrast on CT Tube placement/sinus studies Intrathecal Indications (myelography, CSF leak studies) Low osmolar Intraarticular Indications MR/CT IV: Iodine based (non-ionics, ionic agents) Gadolinium (Other MR agents) Uses: Improving soft tissue contrast Solid organs Vascular structures Inflammation Renal collecting systems Bladder I 2. Orientation to radiology department (specific to individual programs) 2.1. Ordering urgent/routine studies Institutional methods of ordering routine studies Institutional methods of ordering urgent studies Importance of clinical information (protocoling, interpretation, billing) Request legibility Contact information 2.2. Getting wet readings Office hours/on call 2.3. Accessing reports Dictation system/written Preliminary versus final reports 3. Use of PACS system (specific to individual programs) Accessing images Manipulating images Downloading images for presentations Importance of reading reports Confidentiality/legal issues 4. Radiation safety and risks 4.1. Risks associated with radiation exposure Hematological malignancies Solid organ malignancies 10
  • 11. NMSCR 1/30/2015 Local skin effects Teratogenetic effects ALARA principle 4.2. CXR equivalents of common examinations (or use period natural exposure) Lumbar spine films 20 KUB 75 VQ scan 80 Bone scan 180 Myocardial perfusion250 Chest CT 400 (approx. 20 yrs of 2 view mammograms) Abdo/Pelvic CT 750 4.3. Methods to reduce radiation exposure Reduction in unnecessary examinations (e.g. daily ICU films) Dose reduction (CT) Exposure time reduction (fluoroscopy) Use of US and MRI 4.4. Age dependance of radiation sensitivity Cancer incidence with age exposure Importance of reducing pediatric radiation exposure 5. Imaging in pregnancy and breast feeding No proven risk to fetus of ultrasound No proven risk to fetus of MRI, but avoid in first trimester if possible Importance of performing examinations if medically necessary Importance of re-evaluating “set protocols” e.g. trauma protocols in a pregnant patient Dose reduction Shielding Tc99m tracers safe in pregnancy, other tracers avoided Shielding unhelpful in nuclear medicine, hydration and bladder emptying Breast feeding withheld for at least 4 half-lives of tracer Use of intravenous iodine based contrast agents not contraindicated when required for diagnosis of maternal condition. After the 1st trimester, gadolinium occassionally used for strong indications (e.g ovarian tumors) 5.1. Preferred studies (limitations): Dysnea – CXR (shielded) Fetal scanning – ultrasound, MRI for evaluation complex fetal anomalies Renal stones – ultrasound. Limited by physiological hydro. Low dose spiral CT may be used if indicated within fetal dose guidelines Trauma - MRI or ultrasound for first choice, but CT if needed. Suspected appendicitis: ultrasound, but maybe limited by fetal position/maternal size, low dose spiral CT, (laparoscopy may be study of choice in high suspicion case) Suspected PE – CXR then perfusion scan +/- ventilation scan if abnormal 5.2. Studies that should be performed if absolutely necessary with shielding if possible KUB Limited IVP CT, but limited dose 11
  • 12. NMSCR 1/30/2015 5.3. Contraindicated studies (except in very rare life threatening cases) Angiography CT pelvis (except rare cases) GI Fluoroscopy (except in very rare cases) 131 I therapeutic or diagnostic dose 201 Tl scans 67 Ga 111 In white cell and other scans 6. Other ‘risks’ of radiology 6.1. Contrast media Complications Local pain and vomiting Extravasations with tissue necrosis Allergic reactions Incidence (minor 3+%, severe <0.5%, fatal 1:150,000) Renal failure Aspiration (barium vs ionic vs non-ionic) Low risk of intra-luminal contrast High risk groups Allergy (asthma, previous reaction, not shellfish or iodine allergy) Renal failure Age > 65 Diabetic (hydrate, consider avoiding if >1.6)) Increased creatinine (>1.6 hydrate if necessary, >2.0 contraindicated) Myeloma (contraindicated in the presence of proteinuria) Metformin therapy (withhold 2 days after contrast) Methods to reduce/manage contrast complications Low osmolar contrast media (cost implications) Gadolium MRI Steroid and antihistamine protocols Pre and post hydration N-acetyl cysteine CO2 angiography 6.2. Risks of percutaneous biopsies and drainage procedures Bleeding, infection, organ damage, pneumothorax 6.3. Claustrophobia MRI>CT>nucs or fluoro 6.4. Complications specific to fluoroscopy Bowel perforation Barium impaction Barium mediastinitis and peritonitis Aspiration of contrast media (barium vs. ionic vs. non-ionic contrast media 12
  • 13. NMSCR 1/30/2015 6.5. Complications specific to nuclear medicine Allergic reactions extremely rare except antibody studies Persantine/adenosine reactions 6.6. Complications specific to MRI Ferromagnetic displacement (eye debris, aneurysm clips, objects) Electrical interference (pacemakers, defibrillators, neuro-stimulators) Artifacts from metallic prostheses and debris 6.7. Complications specific to pulmonary angiography Risk of pulmonary angiography I(R) (approx. 0.2% fatal, 2% serious adverse events) Contraindications: severe pulmonary htn, recent MI, LBBB, contrast allergy 6.8. False positive and negative studies Additional physical and financial risks of further imaging or biopsy Emotional risks (e.g. screening mammography) Risks of non-treatment in false negative cases 7. Financial costs Patient and society Comparative charges for common examinations at student’s institution Example: Examination $ charged as multiples of X (global fee) CXR 1 Abdominal series 2 CT chest with contrast 10 Chest, abdomen, pelvic CT 17 CT abdomen with contrast 9 MRI abdomen with contrast 12 MRI of lumbar spine, no contrast 12 Abdominal US 4 UGI series with SBFT 4 IVP 4 Barium enema 3 Colonoscopy 16 Bone scan 5 PET scan 16 VQ scan 6 13
  • 14. NMSCR 1/30/2015 Chest Imaging Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area CXR: PA, lat, AP, decubitus views, lordotic view, expiratory view, supine (limitations) CT: When contrast helps, definition and use of: high resolution CT, CT pulmonary and aortic angiography MRI: Pulmonary angiography Nuclear medicine: (FDG lung cancer) – covered under nucs curriculum VQ scans- covered under nucs curriculum 1.2. Patient preparation and education Fasting 6hr for PET FDG scan Need to hold breath for CT, respiratory gating MR 1.3. Studies that ideally should be watched during elective period or clinical rotations PA and lateral CXR Portable CXR Chest CT Chest tube insertion and/or thoracocentesis 2. Normal anatomy 2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation) CXR (PA and lateral) and CT Lungs: RUL, RLL, RML, LLL, LUL Costophrenic and cardiophrenic angles Minor and major fissures Trachea and carina Right and left main bronchi Retrosternal clear space Heart: RV, RA, LV, LA Aorta, pulmonary outflow track Pericardium Pulmonary veins Position of heart valves Mediastinum: SVC Carotid and subclavian vessels 14
  • 15. NMSCR 1/30/2015 Aortic knob, AP window Right paratracheal line Azygous vein Carina Right and left main pulmonary arteries Azygo-esophageal line Right paraspinal line Left paraaortic line Bone and soft tissues Shoulders, C spine, thoracic spine Scapulae Clavicles Sternum Diaphragms Liver Stomach Colon Common normal variants Azygous lobe Cervical ribs Mediastinal lipomatosis Pericardial fat pads Pulmonary angiogram (CT and conventional) and MRI Right and left main pulmonary arteries Ascending and descending aorta Take off of great vessels 3. Pathological conditions The student should be taught a system (chosen by the tutor) of surveying every CXR for abnormalities to ensure that they do not ‘gestalt’ films. 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of: Atelectasis: Linear Lobar: LLL, LUL, RLL, RML, RUL Indirect signs (mediastinal, hilar, diaphragmatic and fissure shift) Total lung atelectasis Pneumonia: Appearance of and DDX of consolidation (fluid, blood, malignancy, pus) Silhouette and spine signs Air bronchograms Lobar patterns: LLL, LUL, RLL, RML, RUL Viral/atypical patterns: mycoplasma, PCP Vascular abnormalities Recognition and differential of dilated aorta Appearance of great vessel ectasia Thoracic aortic aneurysm Ruptured aorta Aortic dissection 15
  • 16. NMSCR 1/30/2015 Pulmonary hypertension PE (CXR, CT) Pleural abnormalities Pleural effusion (small, large, subpulmonic, decub films, supine and upright) Pneumothorax (small, large, supine and upright, decub and expiratory films, tension) Pneumomediastinum Pleural thickening and calcifications (asbestos exposure) Pseudotumor Empyema Cardiac abnormalities Cardiomegaly (individual chamber enlargement, generalized cardiomegaly) Cardiac failure (pulmonary venous hypertension, interstitial edema, alveolar edema) Aortic and mitral valve and annulus calcifications Masses ‘Danger zones’ for missing tumors Non-small cell lung cancer (hilar mass, parenchymal tumor) Anterior mediastinal mass (Hodgkins, goiter, thymoma etc) Cavitating mass Goitre Granuloma Distinguishing which mediastinal compartment masses are in Adenopathy Lymphoma Sarcoidosis Interstitial abnormalities Interstitial edema Emphysema Extensive fibrosis (honeycombing, cystic fibrosis) Other Distinguishing causes of hemithorax opacification (effusion, vs atelectasis vs pneumonia vs pneumonectomy). Meaning of ‘ground glass opacity’ on CXR/CT 3.2. Iatrogenic pathology Malplaced Dobhoff/NG (eg. esophagus, trachea, bronchus) Malplaced central venous catheters (jugular, subclavian, right atrium) Malplaced endotracheal tube (too high, low, esophageal) Other misplaced wires, catheters 3.3. Emergency “don’t miss” findings (CXR) Tension pneumothorax Supine pneumothorax (deep sulcus sign) LUL collapse Pulmonary edema (interstitial and alveolar) Sub-diaphragmatic air Pneumomediastinum Signs of aortic dissection Aortic rupture (supine CXR, CT) Dobhoff in trachea/bronchus 16
  • 17. NMSCR 1/30/2015 3.4. Diagnostic situations/conditions that do NOT require imaging Suspected rib fractures (unless complications then PA/Lat CXR, not rib films) Pre-op CXR in assymptomatic individuals 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures are beneficial Pigtail chest tubes (when are they appropriate) for effusions and pneumothorax Thoracocentesis (when is image guidance not needed), ultrasound, CT, Fluoro Lung biopsy (CT, fluoro). Risk of pneumothorax Lung abscess (when percutaneous drainage is required) 5. Imaging algorithms (appropriateness criteria) 5.1. Appropriate imaging management algorithms for common diagnostic situations Screening for metastases (CXR vs CT) Staging for lung cancer (CXR vs CT vs PET) Appropriate imaging for suspected pulmonary embolus (CT pulmonary angiography vs VQ vs angio vs leg venous doppler) Appropriate imaging in trauma (when to do C/A/P CT scan) Appropriate imaging for suspected aortic trauma (when to do CT angiogram, alternatives) Appropriate imaging for suspected aortic dissection (CT vs MRI vs TEE) Appropriate imaging for suspected small pneumothorax (use of expiratory/decubitus views) Appropriate imaging for suspected foreign body aspiration (kids, decub, expiratory views, fluoro) Appropriate imaging for SPN seen on CXR (old films, follow up, CT, PET, biopsy) Appropriate imaging for pneumonia (importance of follow up films, when to consider neoplasm workup) Appropriate imaging for pneumomediastinum (when is additional imaging required) Appropriate imaging for dysnea in non-immunocomprised patient Appropriate imaging for dysnea in immunocompromised patient (CXR vs CT) Appropriate imaging for suspected interstitial lung disease (CXR vs regular CT vs high res CT) Appropriate imaging for total hemithorax opacification (not decubs) 5.2. Cost-effective imaging Value of obtaining older studies CXR vs CT for metastatic evaluation CXR vs CT for lung cancer follow up Daily ICU film indications Lung cancer screening controversies PET for lung cancer diagnosis and staging 5.3. Incorporating imaging findings into patient management Effects of pre-test probabilities Management of the low or intermediate probability VQ scan in high suspicion patient Management of the negative CT pulmonary angiogram in the high suspicion patient, problems with limited quality studies Management of the benign appearing SPN in low risk patient Management of the benign appearing SPN in high risk patient 17
  • 18. NMSCR 1/30/2015 Management of the normal supine CXR in high risk trauma patient 18
  • 19. NMSCR 1/30/2015 Abdominal Imaging Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area KUB – upright, supine, use of decubitus views Barium swallow (and modified) Upper GI Small bowel follow through Double and single contrast enemas Water soluble enema IVP Cystogram/VCUG RUQ ultrasound “Abdominal” ultrasound Pelvic ultrasound CT abdomen and pelvis Hepatobiliary study (see nucs section) Renal scintigraphy (see nucs section) MRI abdomen and pelvis 1.2. Patient preparation and education Bowel preparation for enemas (elderly patient risks) Oral contrast for CT (diabetic contrast) Hydration following barium studies Hydration pre and post IV contrast Rationale for bladder filling for pelvic ultrasound Use of transvaginal/rectal ultrasound Claustrophobia (MR>CT) 1.3. Studies that should be watched during elective period UGI Barium enema CT scan RUQ ultrasound Pelvic ultrasound VCUG 2. Normal anatomy 2.1. Structures that should be identified on each modality (where visible) with emphasis on cross- modality correlation especially CT-Ultrasound-Fluoro-KUB Esophagus Stomach Duodenum Small bowel Colon Liver Gallbladder Spleen 19
  • 20. NMSCR 1/30/2015 Pancreas Aorta IVC Kidneys Ureters Bladder Uterus Ovaries 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of: KUB: Free air (see below) Small bowel obstruction Colonic obstruction Cecal and sigmoid volvulus Illeus Renal and ureteric calculi Gallstones Calcified aortic aneurysm Benign calcifications (phleboliths, vascular etc) Fluoroscopic studies: Malignant colonic stricture (obvious) Hiatal hernia Esophageal tumor (obvious) Gastric ulcer Ultrasound: Hydronephrosis Biliary obstruction Gallstones Acute cholecystitis CT: Liver metastases AAA (with and without rupture) Hydronephrosis Traumatic liver and splenic ruptures Ascites 3.2. Emergency “don’t miss” findings Free air – upright chest, supine, decubitus and upright KUB, CT SBO Cecal and sigmoid volvulus Free fluid on CT 3.3. Diagnostic situations/conditions unlikely to benefit from imaging Ultrasound unhelpful for non-localizable abdominal pain Renal failure in the setting of ICU patient (R/O hydronephrosis) 20
  • 21. NMSCR 1/30/2015 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures are beneficial Advantages and disadvantages of CT vs US guided procedures Hydronephrosis Abscess drainage When US required for paracentesis Liver and renal biopsies Biliary obstruction (ERCP guided stenting vs percutaneous) TIPS procedures AAA endovascular grafts Renal stents 5. Imaging management (appropriateness criteria) 5.1. Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging When to order the barium swallow versus upper GI When to order the small bowel follow through Double versus single contrast enemas – discuss with radiologist Appropriate imaging for suspected renal calculi (KUB vs IVP vs non-contrast CT) Appropriate imaging for painless hematuria Appropriate imaging for suspected acute cholecystitis (US vs CT vs hepatobiliary study) Staging for malignant disease (CT vs MRI) Appropriate imaging for acute pancreatitis (US vs CT, unhelpful in early disease) Appropriate imaging for suspected appendicitis in adults/children (ultrasound vs CT vs KUB) Appropriate imaging for rectal bleeding (acute vs chronic, barium enema vs colonoscopy) Appropriate imaging for upper GI bleeding (acute vs chronic, UGI vs endoscopy) Appropriate imaging for female pelvic pain (pregnant versus non-pregnant) Appropriate imaging for suspected ruptured AAA Appropriate imaging for SBO Appropriate imaging for colonic obstruction/illeus Appropriate imaging for suspected diverticulitis Appropriate imaging for jaundice Appropriate imaging for renal failure 5.2. Incorporating imaging findings into patient management including impact of pre-test probabilities Management of the image negative, high pretest probability suspected acute cholecystitis patient Management of the image negative patient with suspected ectopic pregnancy 21
  • 22. NMSCR 1/30/2015 Musculoskeletal Radiology Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area Plain films Importance of different projections, fractures may be occult if not displaced, difficulties in complex bones, importance of focused study, important views including scaphoid view, radial head view) CT Good for bone detail, calcifications Use of intravenous and intra-articular contrast MR Good for soft tissues, marrow, ligaments, multiple plains, marrow edema for occult fractures Use of intravenous and intra-articular contrast Fluoroscopy Guidance for biopsy, analysis of motion Ultrasound Superficial tendons, ligaments, foreign bodies, superficial infections, joint effusions DEXA for bone mineral density 1.2. Patient preparation and education No driving after shoulder arthrogram Post-procedure pain management Importance of holding still during CT/MR 1.3. Studies that should be watched during elective period or clinical rotations Extremity plain film Arthrogram Shoulder/hip/knee MR Trauma series Fluoroscopy for assessment of stability/motion 2. Normal anatomy 2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation) Identification of major parts of : Humerus, radius, ulna, carpal bones, metacarpals and phalanges, femur, fibula, tibia, tarsal bones, calcaneus, metatarsals, vertebrae, ribs, pelvis, clavicles and scapulae. Structure of long bones: Diaphysis, metaphysis, epiphysis Common normal variants: 22
  • 23. NMSCR 1/30/2015 Cervical ribs, extra lumbar vertebra, bipartite patella Soft tissues Identification of and significance of normal soft-tissue fat interface, fat pads Identification of major muscle groups felt to be beyond medical student level 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of : Trauma: Joint effusions Knee Elbow Appendicular Fractures Descriptive words for fracture orientation, displacement and angulation Significance of intraarticular displacement Significance of physeal plate involvement Fracture ‘evolution’ on delayed films Disuse osteopenia Femoral neck, intertrocanteric fracture Medial and lateral malleolar fractures Base of 5th metatarsal fracture Lisfranc fracture/dislocation Spinal compression fractures Spinal burst fracture Metacarpal/phalangeal fractures Scaphoid fracture (importance of scaphoid view) Colles/Smith fracture Radial head (signs elbow effusion) Distal humeral fracture in a child (signs elbow effusion) Humeral head fracture Clavicle fracture Metaphyseal corner factures (bucket handle) in child abuse Tibial plateau fracture Toddler fracture tibia Common Spinal Fractures Compression fractures thoracic and lumbar spines Burst fractures (signs canal narrowing) Importance of identifying cervical lines and soft tissues on lateral film C1 Jefferson fracture C2 fractures, dens and Hangman’s Anterior subluxation flexion injury Posterior ligamentous injury (subtle signs of) Spinous process fracture Bilateral jumped facets Dislocations Anterior shoulder dislocation and Hill Sachs fracture Phalangeal dislocations 23
  • 24. NMSCR 1/30/2015 Hip dislocation Soft tissue injuries Rotator cuff injury Knee meniscal injury Arthritis: Osteoarthritis Inflammatory arthritis Septic arthritis Tumors: Primary osteosarcoma Bone metastasis - blastic vs lytic (significance for bone scan) Myeloma Metabolic bone disease: Osteoporosis Infections: Osteomyelitis Cellulitis 3.2. Emergency “don’t miss” findings Septic joint Fracture with extension into joint Elbow joint effusion, radial head fracture Shoulder dislocation Abnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury (Child abuse see pediatric section) 3.3. Diagnostic situations/conditions unlikely to benefit from imaging Ankle sprain 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures may be beneficial Osteopenic vertebral collapse – vertebroplasty Bone biopsy for suspected tumors Joint aspiration for suspected septic joints Arthrography (CT or not) for suspected rotator cuff disease 5. Imaging algorithms (appropriateness criteria) 5.1. Appropriate imaging management algorithms for common diagnostic situations including cost-effective imaging 24
  • 25. NMSCR 1/30/2015 Appropriate imaging for chronic back pain in an adult (no imaging vs plain films vs CT vs MR vs myelography) Appropriate imaging for chronic back pain in a child (as above, plus bone scan) Appropriate imaging for acute back pain Use of the ‘trauma series”, indications for further imaging Indications for plain films of the neck in trauma Indications for CT of the neck in trauma Indications for MR of the neck in trauma Appropriate imaging for metastatic disease, plain film correlation with bone scan Appropriate imaging for shoulder pain (plain films vs CT arthrogram vs MR+/- arthrogram vs fluoroscopic arthrography) Appropriate imaging for suspected occult hip fracture (CT vs MRI vs bone scan) Appropriate imaging for the diabetic foot (plain films vs MR vs bone scan vs white cell scan) Appropriate imaging for suspected osteomyelitis in non-diabetic (plain films vs MR vs bone scan vs white cell scan) 5.2. Incorporating imaging findings into patient management including effects of pre-test probabilities Management of the high suspicion hip fracture with negative plain films Management of patients with low suspicion c-spine injuries and normal plain films (esp. whiplash injuries) Management of patients with persistant pain following injury, imaging negative (use of delayed films, bone scans, MR) 25
  • 26. NMSCR 1/30/2015 Interventional Radiology Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used in IR Imaging Fluoroscopy – risks of significant radiation dose, multiangles Angiography CO2 studies in patients with renal failure Image guided biopsy techniques Fluoroscopy-real time visualization of structures, radiation dose, (chest, bone biopsies, tube placements) CT (CT fluoro)-better visualization of small internal structures than fluoroscopy, radiation, time consuming, any area, can use stereotactic techniques MR-limitations due to magnetic field, becoming resolved with new equipment US-real time visualization, limited depth, no radiation, limited by gas shadows, (renal, breast, liver, thoraco and paracentesis) Image guided therapy Drainage tube placements (types) Central venous catheters (types) Stent placements, vascular and non-vascular Angioplasty Radioablation Chemoablation 1.2. Patient preparation and education Pre-procedure labs required (coags, platelets, renal function) Peri- and post-procedure pain management Risks and contraindications of sedative drugs 1.3. Studies that should be watched during elective period or during clinical rotations Percutaneous biopsy Angiographic study Stent placement/angioplasty Central venous access line placement Pigtail catheter placement 1.4. Diagnostic situations/conditions unlikely to benefit from image guided procedures Inaccessible lesions Limitations due to volume of tissue required (biopsy) Very small lesions Lesions too hazardous to access (e.g. blood vessels) 2. Normal anatomy 26
  • 27. NMSCR 1/30/2015 2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation) Refer to organ specific curriculae 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of on diagnostic IR studies during radiology or clinical rotations Vascular Peripheral vascular stenosis AAA Renal stenosis GI bleed or other site of hemorrhage Cerebral aneurysm Carotid stenosis Non-vascular Ureteric/UPJ obstruction 3.2. Emergency “don’t miss” findings IR is generally not used to make initial imaging diagnoses, but to obtain tissue or treat known conditions. Interpretation beyond the scope of medical student curriculum. 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures may be beneficial Diagnostic studies Stroke Cerebral hemorrhage Peripheral ischemia Bowel ischemia Vascular aneurysms (traumatic and non-traumatic) Biopsy procedures Lung tumors Liver masses Pancreatic mass Other mediastinal, abdominal and pelvic masses Bone tumors Drainage procedures Abscesses – lung, abdomen, pelvic Thoracocentesis and pleurodesis for pleural effusions Pneumothorax (pigtail, Heimlich valve) Paracentesis for ascites Ureteric obstruction (nephrostomy tube, internal/eternal drainage) Biliary obstruction Angioplasty, direct intravascular thrombolysis and stent placements Peripheral ischemia 27
  • 28. NMSCR 1/30/2015 Bowel ischemia Renal hypertension Venous stenosis/thrombosis (large central or pulmonary emboli) Biliary strictures Endovascular AAA repair Great vessel stenosis Embolization procedures Cerebral and extracerebral aneuryms Persistent epistaxis Persistent hemoptysis GI hemorrhage Cerebral AVMs Post-traumatic hemorrhage – aortic, spleen, liver, pelvic, limb Fibroids Varicocele Access procedures Chemo/pharmacotherapy: Central venous access – PICC, Dialysis catheters, subcutaneous ports Feeding Gastrostomy tubes Jejunostomy tubes (reflux rationale) Others Portal hypertension – TIPS Pulmonary emboli/DVT – IVC filter placement Infertility - fallopian tube catheterization Ostopenic vertebral body collapse - vertebroplasty 5. Imaging algorithms (appropriateness criteria) 5.1. Appropriate imaging management algorithms for common diagnostic/therapeutic situations including cost-effective imaging Indications for placement of an IVC filter in DVT/PE Management of for small pneumothorax (pigtail vs chest tube) Management of recurrent pleural effusions (taps vs tubes vs pleurodesis) Management of lung mass (surgical vs percutaneous approach for biopsy) Management of inoperable tumors (chemo or RT vs chemoablation vs cryo vs RF) Management of obstructive jaundice (percutaneous vs endoscopic stent) Management of feeding tubes in patients with oropharyngeal tumors (gastrostomy vs jejunostomy vs surgical placement anagement) Management of patient with large embolus/thrombus (intravenous vs direct thrombolysis vs embolectomy) Management of fibroids (surgical vs embolism) Management of persistent epistaxis (surgical vs IR) Management of portal hypertension (surgical vs TIPS vs endoscopic sclerotherapy) Selection of type of venous access (Hickman vs CVL vs portacath vs PICC) Management of dialysis access (central vs peripheral) Management of pancreatic head tumors (percutaneous vs endoscopic biopsies) 28
  • 29. NMSCR 1/30/2015 Emergency Radiology Note: While any condition may present to the emergency room, this curriculum focuses on those conditions that commonly present to the emergency room physician. Many overlap with the other organ-specific curricular. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area Plain films (see core curriculum), include use of portable studies, trauma series CT: “trauma study” Ultrasound for intraperitoneal fluid 1.2. Patient preparation and education Short CT preps for trauma Education about lack of need for imaging in certain conditions 1.3. Studies that ideally should be watched during elective period or during clinical rotations CT chest/abdomen/pelvis CT head/C-spine Plain film trauma series Limited abdominal ultrasound for fluid 2. Normal anatomy 2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation) 1.1.1. Chest: See chest curriculum 1.1.2. Abdomen: See Abdominal curriculum 1.1.3. Head: See Neuro curriculum 1.1.4. Musculoskeletal: See MS curriculum 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of during radiology or clinical rotations: Trauma Major organ injury (CT/plain films) Liver and splenic lacerations Aortic laceration Hemomediastium Diaphragmatic rupture Duodenal/small bowel laceration Renal laceration Bladder perforation (indications for cystography) Pneumothorax including signs of tension, supine and upright Hemothorax Rib fractures (significance of upper and lower rib fractures, posterior rib fractures in child abuse) Common appendicular fractures/dislocations including: Metacarpal/phalangeal fractures Scaphoid fracture (importance of scaphoid view) 29
  • 30. NMSCR 1/30/2015 Colles/Smith fracture Radial head (signs elbow effusion) Distal humeral fracture in a child (signs elbow effusion) Humeral head fracture Anterior shoulder dislocation and Hill Sachs fracture Clavicle fracture Femoral neck and intertrochanteric fractures Femoral shaft fracture Metaphyseal corner factures (bucket handle) in child abuse Tibial plateau fracture Toddler fracture tibia Medial and lateral malleolar fractures Ligamentous disruption of mortise joint ankle Base 5th metatarsal fracture Lisfranc fracture/dislocation Importance of intra-articular extension Importance of physeal plate involvement Importance of displacement and angulation Common spinal injuries (Plain films and CT) Compression fractures thoracic and lumbar spines Burst fractures (signs canal narrowing) Importance of identifying cervical lines and soft tissues on lateral film C1 Jefferson fracture C2 fractures, dens and Hangman’s Anterior subluxation flexion injury Posterior ligamentous injury (subtle signs of) Spinous process fracture Bilateral jumped facets Spinal epidural hematoma (MRI) Cord contusion (MRI) Neurological injuries Subdural hematoma Epidural hematoma Diffuse axonal injury (MR) Parenchymal contusion/hemorrhage Non-traumatic Chest Lobar pneumonia (see chest section) Atypical pneumonias such as mycoplasma, PCP Cardiac failure (interstitial and pulmonary edema) Cardiomegaly (chamber enlargement) Aortic dissection (plain film, CT) Pulmonary embolus (plain film signs, CT) Pneumomediastinum Abdomen Appendicitis (CT) Acute cholecystitis (U/S, hepatobiliary study) Diverticulitis (CT) Ruptured abdominal aortic aneurysm (CT, Ultrasound) Renal calculi (KUB, CT) Intraperitoneal free air Small bowel obstruction 30
  • 31. NMSCR 1/30/2015 Large bowel obstruction Testicular torsion Musculoskeletal Acute osteomyelitis Septic arthritis Neurological Disorders Acute and subacute infarction (CT, MRI) Subarachnoid hemorrhage (CT) Ob/Gyn Disorders Ectopic pregnancy (u/s) Missed/completed abortion Ovarian torsion Ovarian cyst/cyst rupture Placental abruption Pediatric Disorders (specific) Aspirated foreign body in a child (CXR, fluoro) Intersusception (KUB, air vs barium enema) Bowel volvulus Bronchiolitis Epiglottitis Croup 3.2. Iatrogenic pathology Misplaced naso/oral gastric tubes Correct position of chest tubes Correct position of endotracheal tubes Correct position of central lines Iatrogenic pneumothorax and pneumomediastinum 3.3. Emergency “don’t miss” findings Tension pneumothorax Aortic rupture Aortic dissection Diaphragmatic rupture Child abuse – posterior rib fractures, metaphyseal corner fractures, bilateral subdurals of different ages Cerebral herniation (CT) Small or isodense subdural hematomas Testicular torsion Abnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury 3.4. Diagnostic situations/conditions unlikely to benefit from imaging Use of CXR rather than rib films in suspected rib fractures Coccygeal fractures (no imaging) Ankle injuries that do not fulfill Ottawa ankle criteria Ambulating patients for r/o tibia/fibula fxs 31
  • 32. NMSCR 1/30/2015 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures may be beneficial Ultrasound guided thoracocentesis and paracentesis Pigtail catheter placement for pneumothorax 5. Imaging algorithms (appropriateness criteria) and cost effective imaging 5.1. Appropriate imaging algorithms for common diagnostic situations Criteria for performing CT (C/A/P) in trauma patient Criteria for performing limited ultrasound for abdominal fluid in trauma patient Criteria for performing CT c-spine in neck injuries Indications for performing CT prior to lumbar puncture Criteria for head CT for headache Appropriate imaging for suspected acute cholecystitis (U/S vs CT vs hepatobiliary scan) Appropriate imaging for suspected appendicitis (child vs adult) Appropriate imaging for suspected CVA (CT vs MRI) Appropriate imaging for suspected PE (CT vs VQ vs angio) Appropriate imaging for suspected ectopic pregnancy (importance of βHCG level) Appropriate imaging for suspected foreign body aspiration in child (fluoro vs exp vs decubitus views) Appropriate imaging for suspected renal stones (CT vs IVP vs ultrasound) Appropriate imaging for suspected aortic dissection (CT vs MRI vs transesophageal echo) Appropriate imaging for suspected occult hip fracture (bone scan vs MRI vs CT) Appropriate imaging for suspected skull and facial fractures (plain films vs CT) Appropriate imaging for suspected epiglottitis Appropriate imaging for suspected DVT Appropriate imaging for suspected ruptured aortic aneurym Appropriate imaging for suspected bladder rupture (CT vs fluoro vs both) Appropriate imaging for suspected pelvic inflammatory disease Appropriate imaging for the child with hip pain/limp (plain film vs U/S vs bone scan vs MRI vs CT) Appropriate imaging for the child with suspected child abuse (skeletal survey, bone scan) 5.2. Incorporating imaging findings into patient management including effects of pre-test probabilities Management of suspected ectopic pregnancy when no gestational sac seen Management of the high suspicion but imaging negative ?PE case 32
  • 33. NMSCR 1/30/2015 Women’s Imaging Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized woman’s imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area Mammography (analogue, digital) CC and MLO positioning Rationale for compression Screening versus diagnostic mammography Indications for diagnostic mammography Palpable mass Call back from screening Focal pain Short interval follow-up from prior ACR 3 mammogram Bloody nipple discharge Ultrasound Breast Transabdominal Transvaginal Hysterosonograms Hysterosalpingograms MRI Breast Pelvic Fetal Nuclear medicine (sestamibi, PET) 1.2. Patient preparation and education Breast imaging Sensitivity and specificity of screening mammography Patient education regarding benefits and risks of screening mammography Increasing patient compliance with screening protocols Understanding the screening call-back system Radiation risk and cumulative exposure from screening mammography Pelvic/fetal ultrasound Use of transvaginal probes Importance of bladder filling on for some pelvic scans Appropriate timing of fetal ultrasound scans (dating, morphology) Medical test not family entertainment Sexing of fetuses not always possible Accuracy of dating +/- 10% Use of tranvaginal ultrasound in early pregnancy Importance of understanding limitations of ultrasound Sensitivity only about 80-85% in diagnosing anomalies Normal scan ≠ normal baby Small fetuses (early scans) Obese patients 33
  • 34. NMSCR 1/30/2015 1.3. Studies that should be watched during elective period or during clinical rotations Breast imaging Screening mammogram Breast ultrasound Breast biopsy (stereo and ultrasound) Needle localization Pelvic/fetal ultrasound Transvaginal and transabdominal ultrasound Early pregnancy (6-10 w) transvaginal scan Morphology (18-20) scan 2. Normal anatomy 2.1. Structures that should be identified on each modality with emphasis on cross-modality correlation Breast imaging Fat versus glandular tissue Concept of marked inter-patient variability Pelvic/fetal ultrasound Uterus Ovaries Cervix Cul-de-sac Early fetal scan: yolk sac, gestational sac, fetal pole Normal early OB milestones (gest sac 5w, yolk sac 5.5w, heart beat 6w) Morphology scan: Head, abdomen, chest, limbs, cord, placenta More detail not felt appropriate at medical student level 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of: Breast imaging Recognition not required at general medical student level. Benign masses (cysts, fibroadenomas) Malignant masses (obvious cancer) Calcifications (benign, malignant) Pelvic/fetal ultrasound Fibroids Thickened endometrium Ovarian cyst/solid mass Ectopic pregnancy with ‘empty’ uterus Knowledge of the types of major anomalies that can be identified by ultrasound, and those that cannot: Neuro (hydrocephalus, Chiari malforms, neural tube defects, anencephaly, etc) 34
  • 35. NMSCR 1/30/2015 GI (omphalocele, gastroschisis, duodenal atresia) Chest (thoracic masses, major cardiac anomalies) MS (dwarfism, osteogenesis imperfecta, club foot) Placental abnormalies (previa, abruption, molar) Interpretation of pathological findings on OB ultrasound felt to be not appropriate at medical student level. 3.2. Emergency “don’t miss” findings Recognition not required at general medical student level 3.3. Diagnostic situations/conditions unlikely to benefit from imaging (other than routine screening mammography if >40 yrs) Diffuse breast pain Bilateral breast discharge Expressible only, non-bloody discharge Large areas of breast “thickening” esp. if bilateral Waxing and waning masses Ultrasound in the very early pregnancy (<5w or when serum βHCG<1000 IU) 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures are beneficial Breast Rationale for performing core biopsies Decreased scar/morbidity Pre-operative planning Reductions in repeat surgical rates Needle-wire localizations for non-palpable abnormalities Indications for stereotactic or ultrasound guided breast biopsies Non-palpable masses, asymmetric densities, calcifications Palpable masses Pelvic/fetal ultrasound Use of ultrasound in performing amniocentesis and fetal therapeutic procedures Use of sonohystography Use of uterine artery embolization Use of fallopian tube catheterization 5. Imaging algorithms (appropriateness criteria) 5.1. Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging Breast Imaging Currently recommended screening protocols (ACR) Effect of screening mammography on breast cancer mortality rates Mammography screening in 40-50 age group controversies 35
  • 36. NMSCR 1/30/2015 Mammography screening in high-risk groups When to stop screening Evaluation of palpable breast masses Evaluation of palpable masses in young patients Surgical evaluation of questionable palpable findings Use of ultrasound for cystic versus solid lesions Pelvic/fetal ultrasound Appropriate imaging for female pelvic pain (pregnant versus non-pregnant) Appropriate imaging for abnormal menstruation (when and who to scan) Appropriate imaging for pelvic masses (US vs MR vs CT) Appropriate imaging for infertility (US vs hysterosonography vs MR) Appropriate imaging for patients with suspected endometriosis (US vs MR vs laparoscopy) Indications for scanning in the first trimester: Bleeding and or pelvic pain: (implantation bleed, subchorionic hematoma, molar pregnancy, incomplete abortion, ectopic pregnancy) Uncertainty of dates - LMP or size larger/smaller than dates (importance of early scans) Prior history of ectopic pregnancy Prior history of multiple pregnancy Infertility treatment (ectopic, multiples, reassurance) Indications for scanning in the second trimester: Anomaly evaluation, especially in conjunction with abnormal maternal serologic screens (ie AFP, maternal triple screen, family or prior sibling with anomaly) Controversies of “screening scan” in low risk patients Size/date discrepancy Bleeding Cervical incompetence No fetal heart by Doppler Amniocentesis Indications for scanning in the third trimester: Size/date discrepancy (fetal biometry) Bleeding (previa/abruption), Cervical incompetence Monitoring of known fetal or placental anomaly No fetal heart by doppler Presentation Cervical incompetence. Assessment of fetal well-being (biophysical profile) – eclampsia, hypertension, multiples, post dates, abnormal non-stress test etc Indications for pelvic MR in non-pregnant woman Staging of cervical and uterine carcinomas Evaluation of ovarian masses Evaluation of congenital abnormalies of the uterus Indications for MRI in pregnancy Trauma Complex neurological anomalies Complex body wall anomalies Concurrent maternal abdo-pelvic disease 36
  • 37. NMSCR 1/30/2015 5.2. Incorporating imaging findings into patient management including effects of pre-test probabilities Breast imaging Meaning of ACR categories 0-5 Significance and Management of ACR 3 findings Management of the image-negative palpable mass Pelvic and fetal ultrasound Importance of knowledge of serum βHCG result when interpreting early OB scan results in patients with pelvic pain or bleeding Importance of incorporating certainty of dates by LMP with ultrasound dating for evaluation of fetal dating and growth restriction as well as first trimester loss. Sensitivity of ultrasound for diagnosis of Down’s syndrome approx. 80% Normal ultrasound approximately halves pre-scan (age + triple screen) risk of Down’s syndrome 37
  • 38. NMSCR 1/30/2015 Neuroimaging Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area NeuroCT and CT of the neck, sinuses and ear NeuroMR Cerebral angiography Spinal imaging-CT Spinal imaging-MR Myelography CTA/MRA 1.2. Patient preparation and education Importance of holding still for long periods for MRI NPO for several hours before IV contrast External halo devices for stereotactic procedures 1.3. Studies that should be watched during elective period or clinical rotations Head or spine CT Head or spine MR Myelography Cerebral angiogram Neurointerventional procedure 2. Normal anatomy 2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation CT vs MR) Lobes of brain Midbrain Brainstem Spinal cord Ventricles Optic nerves Epidural vs subdural vs subarachnoid spaces Carotids, MCA, ACA Sagittal sinus, jugular Vertebral column and discs and nerve roots Anterior vs posterior triangle of the neck Paranasal sinuses Pharynx Larynx 3. Pathological conditions 38
  • 39. NMSCR 1/30/2015 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of: Tumors Intraaxial tumors Metastatic disease Extraaxial tumors Head and neck tumors Infection Cerebral abcess Meningitis Discitis Paraspinal abcess Sinusitis Trauma Subdural hematoma Epidural hematoma Subarachnoid hemorrhage Intracerebral hemorrhage (appearance of blood on MR vs CT, time dependancy) Diffuse axonal injury Cerebral herniation Cervical spine trauma Facial trauma Vascular disease Cerebral aneurysm Stroke: early vs late (atherosclerotic, thrombo/embolic) Vascular malformations Miscellaneous: Demyelinating diseases Dementia (atrophy) Normal age related changes 3.2. Emergency “don’t miss” findings Hemorrhagic stroke Traumatic hemorrhage (subdural, epidural, subarachnoid, intraparenchymal) Signs of increased intracranial pressure, midline shift, Cerebral herniation Hydrocephalus Space occupying lesions Isodense subdurals Bilateral hematomas of different ages in child abuse 3.3. Diagnostic situations/conditions unlikely to benefit from imaging Skull films-NOT indicated in most cases of head trauma Timing for appearance of stroke findings CT for migrainous/recurrent headache 4. Invasive procedures 39
  • 40. NMSCR 1/30/2015 4.1. Identify clinical scenarios where image-guided procedures may be beneficial Treatment of berry aneurysms Biopsy of tumors Treatment of congenital vascular anomalies 5. Imaging algoritms (appropriateness criteria) 5.1. Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging Appropriate imaging in the suspected stroke patient (CT vs MRI) Appropriate imaging in suspected SAH (CTvs MRI vs angio) Appropriate imaging in proven non-traumatic intracerebral hemorrhage (CTA vs MRA vs angio) When to order spine CT vs MR vs plain films Appropriate imaging sequence in spinal trauma Appropriate imaging sequence in facial trauma (plain films vs CT) Appropriate imaging for metastatic disease to CNS (CT vs MRI, contrast) Appropriate imaging for headache (CT vs MR vs none) Appropriate imaging for dizziness Appropriate imaging for seizures Appropriate imaging for dementia Appropriate imaging for meningitis Appropriate imaging for AIDS in the CNS (MR vs PET vs thallium) Appropriate imaging for the suspect CNS tumor recurrence vs radiation necrosis (MR vs PET vs thallium) Imaging sinus disease (plain film vs CT vs MR vs none) When myelography is indicated vs MR When conventional neuroangiography is indicated Appropriate imaging for stroke –early and late (CT vs MR vs angio) Appropriate imaging for TIAs Criteria for performing CT prior to lumbar puncture Vascular lesions that can be managed with interventional angiography Appropriate imaging for encephalitis Appropriate imaging for multiple sclerosis Appropriate imaging for peripheral neuropathies 5.2. Incorporating imaging findings into patient Management including effects of pre-test probabilities Management of MRA negative patient with subarachnoid hemorrhage Management of the stroke patient with evidence of hemorrhage Management of the stroke patient without evidence of hemorrhage (timing) with or without CT evidence of infarct 40
  • 41. NMSCR 1/30/2015 Nuclear Medicine Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area Outline of gamma camera operation Concept of radiopharmaceuticals, in general 99m Tc as most commonly used isotope Concept of 18 F-FDG PET scanning and PET-CT Concept of physiological versus anatomical imaging 1.2. Patient preparation and education Caffeine withholding for cardiac pharmacologic stress testing Fasting for PET scans Iodine containing products for thyroid scanning Requirement for keeping still for 20-50 minutes 1.3. Studies that should be watched during elective period Bone scan or other routine planar study SPECT scan of some type Cardiac stress test and perfusion scan 2. Normal anatomy 2.1. Structures that should be identified on each modality with emphasis on cross-modality correlation Recognize a bone scan Recognize a myocardial perfusion scan (left ventricular walls, right ventricle) Recognize a VQ scan Recognize a PET scan Recognize a hepatobiliary study (identify gallbladder, liver, bowel) Recognize a MUGA 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of Interpretation of nuclear medicine studies felt to be beyond the scope of student curriculum, however they should be shown examples of obvious common clinical entities including: Large pulmonary emboli (VQ scan) Extensive bone metastases (bone scan) Acute fracture (bone scan) Obvious myocardial infarct/ischemia (myocardial perfusion study) Acute cholecystitis (hepatobiliary scan) 41
  • 42. NMSCR 1/30/2015 Toxic nodule (thyroid scan) Graves' disease UPJ obstruction (MAG3/DPTA scan) Metastastic tumor (PET FDG scan) 3.2. Iatrogenic pathology Bile leaks s/p cholecystectomy Ureteral obstruction 3.3. Emergency “don’t miss” findings Emergency interpretation of nuclear medicine studies not expected by students or non-radiology interns/residents 3.4. Diagnostic situations/conditions unlikely to benefit from imaging Delayed imaging in GI bleeding scans Bone scans in myeloma 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures are beneficial Shunt patency studies 5. Imaging algorithms (appropriateness criteria) 5.1. Appropriate imaging algorithms for common diagnostic situations Indications for common nuclear medicine exams: (Tracers used for these exams) Bone scan (99m Tc methylene diphosphonate (MDP)) Metastases Fracture Child abuse (useful knowledge for future pediatricians) Osteomyelitis Thyroid scan (99m Tc pertechnetate, 123 I NaI,131 I NaI) Thyrotoxicosis Thyroid nodules Ventilation perfusion [VQ] scan (99m Tc macro-aggregated albumin, 133 Xe , 99m Tc DPTA aerosol ) Suspected pulmonary embolism Differential lung perfusion Myocardial perfusion imaging (99m Tc Sestamibi, 201 Tl) Suspected ischemia Evaluation of infarct size Post revascularization assessed Pre-operative evaluation of high risk patients e.g AAA MUGA (99m Tc labeled RBC) Ejection fraction and wall motion prior to chemotherapy Evaluation of ischemic heart diease (+/- stress) Hepatobiliary scan (99m Tc DISIDA/mebrofenin) 42
  • 43. NMSCR 1/30/2015 Suspected acute cholecystitis Suspected chronic cholecystitis/biliary dyskinesis (CCK) Renal scan (99m TcDPTA or MAG3 or DMSA) Obstruction Renovascular hypertension Renal infarction Gastrointestinal bleeding scan (99m Tc labeled red blood cells) GI bleed with negative endoscopy Gastric emptying study (99m Tc sulfur colloid labeled egg sandwich) Suspected gastroparesis or gastric outlet obstruction White blood cell [WBC] scan (99m Tc HMPAO or 111 In oxine labeled white blood cells) Osteomyelitis PET scan (18 F Fluorodeoxyglucose – FDG) Cancer diagnosis, staging and restaging Myocardial viability Seizure focus localization Appropriate imaging for ?acute cholecystitis (hepatobiliary scan vs US vs CT) Appropriate imaging for ?pulmonary embolism (VQ vs CT angiogram) Appropriate imaging for GI bleeds (bleeding scan vs CT vs angiogram vs endoscopy) Appropriate imaging for suspected occult fractures (MRI vs delayed plain films vs bone scan) Diagnosis of osteomyelitis (x-ray v bone scan v MRI v WBC scan) 5.2. Incorporating imaging findings into patient Management including the effects of pre-test probabilities Understanding the concept of PIOPED criteria Tumors that may produce false negative bone scans (renal, myeloma, lung, thyroid) Consideration for additional testing in high-risk patients with low or intermediate probability VQ scans Cardiac stress test data effects interpretation of myocardial perfusion studies 43
  • 44. NMSCR 1/30/2015 Pediatrics Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives. 1. Technical aspects 1.1. Techniques used to image this anatomical/physiological area Fluoroscopy-with low dose pulsed fluoroscopy, shielding where possible Plain films-with restraints if necessary CT-with sedation MR-with sedation Ultrasound-no sedation, no radiation, used overall more than in adults including neuroimaging prior to closure of fontanelles Nuclear medicine – may or may not need sedation 1.2. Patient preparation and education Use of ‘pain-free’ child anesthesia services Experienced i.v. teams, use of ‘Emla’ cream before i.v. lines Parents sometimes are in room during procedures Decide whether it is better to have parents in or out Pre-procedure information & preparation for children can be very helpful 1.3. Studies that should be watched during elective period VCUG Barium swallow/UGI Abdominal ultrasound Chest radiograph KUB Cranial ultrasound 2. Normal anatomy 2.1. Structures that should be identified on each modality or at least seen during elective (Emphasis on cross-modality correlation) Chest: Assessment of CXR rotation in baby Normal pulmonary vascularity Heart (noting different ratio heart:thorax in neonate) Thymus Abdomen: Liver Spleen Kidneys Skeletal plain films: Normal appearance of growth plates, identification of metaphysis, physis and epiphysis Order of appearance of ossification centers felt to be beyond student level, but some concept of sequential ossification, e.g. femoral heads not ossified at birth 44
  • 45. NMSCR 1/30/2015 Brain Normal neonatal brain appearance (US, CT) 3. Pathological conditions 3.1. Common pathological conditions/findings that the student should recognize or at least see examples of: Trauma: Growth plate injuries Elbow effusion (significance of) Greenstick fractures, esp distal radial torus fracture, toddler fracture Infections: Pneumonia and round pneumonia Bronchiolitis (hyperinflation) Tumors: Wilm's tumor Neuroblastoma Congenital abnormalities: Example of congenital cyanotic heart disease e.g. Tetralogy of Fallot Pyloric stenosis Vesicouretic reflux (VCUG) Neonates: Neonatal radiology felt beyond general medical student level, for dedicated electives consider: TTN/ hyaline membrane disease Meconium aspiration Pneumonia Bronchopulmonary dysplasia 3.2. Emergency “don’t miss” findings Child abuse – posterior rib fractures, metaphyseal corner fractures, unusual spiral fractures of long bones, signs of old multiple fractures, bilateral subdural hematomas of different ages Pneumoperitoneum Pneumothorax in a neonate 3.3. Diagnostic situations/conditions unlikely to benefit from imaging Chronic abdominal pain Recurrent, uncomplicated asthma 4. Invasive procedures 4.1. Identify clinical scenarios where image-guided procedures may be beneficial Biopsy Abscess drainage PICC line placement Prenatal therapy Sclerotherapy (lymphatic malformations) 45
  • 46. NMSCR 1/30/2015 5. Imaging algorithms (appropriateness criteria) 5.1. Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging Appropriate imaging for suspected appendicitis (US vs CT vs KUB) Appropriate imaging for blunt abdominal trauma (US vs CT) Appropriate imaging for cervical spine injury (when to do CT/MR) Appropriate imaging for the clicky hip (US vs plain films, age dependence) Appropriate imaging for the child with a limp (plain films vs US vs aspiration vs bone scan, joints to image) Appropriate imaging for acute and chronic back pain in children (plain films vs CT vs bone sca with SPECT) Appropriate imaging for suspected child abuse (plain films vs bone scan vs head MR) Appropriate imaging for suspected intussusception (KUB vs air/barium/water enema vs US) Appropriate imaging for a neonate or young infant with bilious vs non-bilious vomiting (UGI vs US vs enema) Appropriate imaging for one or more UTIs in girl/boy (when to image, US vs VCUG vs nuclear cystogram vs IVP) Appropriate imaging for failure to pass meconium (water soluble vs ba enema) Contraindicated studies Intussusception reduction attempt in child with surgical abdomen Abdominal CT in unstable trauma patient 5.2. Incorporating imaging findings into patient management including effects of pre-test probabilities Management of borderline pyloric measurements in projectile vomiting Management of negative plain films in high suspicion bony injuries (e.g. distal humerus) 46
  • 47. NMSCR 1/30/2015 Curriculum Resources The following are lists of potential teaching resources and methods for a student elective or required course in Radiology. These are collated from multiple programs with different resources, program formats and needs, and obviously not all could be applied in any one program. 1. Teaching Methods 1.1. Group based conferences • Didactic slideshow digital/non-digital • Film based/digital “hot seat” case conference • Digital interactive teaching using graphical pad and image manipulation software (e.g. Photoshop or Paintshop Pro) • Case conferences with preview of cases (film, digital, web-based) • Case-based image Management conferences with or without preview of clinical scenarios 1.2. Student presentations • Case based or topic based • Film or digital • To department or just to other students • Posting past presentations as teaching files or examples on websites or CDROMs • Examples of good and bad presentations • Giving them clear guidelines for effective presentation • Assigning staff or residents to assist in case presentation, preview and critique • Image digitization and download workshop • Videotaping presentations for feedback and critique • Development into published case reports • Evaluation by staff/residents/students as part of the elective evaluation • Practical feedback/group discussion following presentations • 1.3. One-on-one based teaching/shadowing • Viewbox observation • Passports or lists of procedures and scans to observe during rotation • Observation of patient experiences • Longitudinal shadowing of specific resident or staff mentor • On-call with resident 47
  • 48. NMSCR 1/30/2015 • “Sub-intern” experience – assigned cases for interpretation • Individual OSCE with structured questions and immediate feedback 1.4. Informal Quizzes • Film or digital slide quiz • Web-based multiple choice quizzes with feedback (with or without cumulative student responses for self- comparison) • CDROM based quizzes • Group or individual effort 1.5. Formal Exams • Film based or digital • Paper or computer based • Multiple choice or textural • Fact based or image based • Timed or open • Powerpoint or web-based • Self-scoring or not • Oral case discussions • Provide immediate immediate/delayed/no feedback and explanatory answers • Multiple or single attempts • Pre-course and post-course examinations • Supervised or honor system • Individual OSCE with structured question 1.6. Games • Team film conference (previewed or not) • Image Jeopardy (blank downloadable from AMSER website) • Image “Who wants to be a Millionaire” • “Radiology Charades” conference (contestant has to describe the findings of a projected film using the correct radiology terminology and the audience who have their backs to the film have to guess what it is). • Use of audience response pads • Use of team/individual reponse buzzers 48
  • 49. NMSCR 1/30/2015 1.7. Self-learning exercises • Student specific teaching files (film or digital) • CDROMS (see below) • Websites (see below) • Web-based tutorials • Imaging algorithms with clinical scenarios • Anatomy identification on images (film or digital) with or without immediate answers • Slide-tape sets • Past student presentations 1.8. Hands-on-practical experiences • Supervised ultrasound practice on other students (with or without atlas reference) • PACS access and image download practice exercise • “Sub-intern” experience – assigned cases for interpretation from regular worklist 2. Websites 2.1. Casefiles • University hospitals of Cleveland and Rainbow Childrens Pedi files (http://www.uhrad.com/pedsarc.htm) Pediatric cases • Pediatricradiology.com (http://www.pediatricradiology.com/) • Extensive links to collections of pediatric cases, and additional links to tutorials on pediatric imaging procedures, congenital heart disease, pediatric measurements and fractures amongst others. • Society of Skeletal Radiology (http://www.skeletalrad.org/teachingfiles.htm) From The Society of Skeletal Radiology site with peer reviewed musculo-skeletal teaching file sites nicely linked • Washington University, Musculoskeletal Teaching file (http://www.rad.washington.edu/mskbook/index.html) Excellent MS teaching file as well as other info • Compare Radiology (http://www.evaluation.idr.med.uni-erlangen.de/Ecomparetitlepage.htm) This site was developed by students and staff at Univ. Erlangen, Germany. It is quite a nice if not "glossy" interactive student teaching tool for general radiology. • Case Western Reserve Radiology Teaching Files (http://www.uhrad.com) There are a lot of teaching files available on this site, which is maintained by University Hospital's Department of Radiology, Cleveland, Ohio 49
  • 50. NMSCR 1/30/2015 • XRay files from the Scottish Radiological Society (http://www.radiology.co.uk/xrayfile/xray/index.htm) The Scottish Radiological Society hosts this site, and there are links as well as tutorials and case presentations • Collaborative Hypertext of Radiology (http://chorus.rad.mcw.edu) CHORUS - Collaborative Hypertext of Radiology. Indexed by disease rather than unknown cases. One of the oldest on-line. University of Wisconsin • Brigham Rad (http://brighamrad.harvard.edu/education.html) Casefiles and “Find the Path” – interactive imaging algorithms for common ER presentations. Several cardiac and nuclear medicine tutorials. 2.2. Teaching programs • Chest X-ray.com (http://www.chestx-ray.com) Site devoted to thoracic imaging with many links. Also has a more public section describing all of the modalities and their protocols. One link is designed for medical students • University of Virgina Radiology Teaching (http://www.med-ed.virginia.edu/courses/rad/radmain.jpg) Excellent radiology tutorial series. • Breast Cancer Detective (http://www.med.umich.edu/lrc/breastcancerdetective) Interactive game teaching basic mammography to medical students from Marilyn Roubidoux at the University of Michigan • Washington University, Musculoskeletal Teaching file (http://www.rad.washington.edu/mskbook/index.html) Excellent MS teaching file as well as other info • Washington University Skeletal Anatomy (http://www.rad.washington.edu/RadAnatomy.html) Review of basic skeletal anatomy on plain films. This site also has more complex MRI-based MS anatomy tutorials • 3-D anatomy teaching modules from University of Iowa (http://www.vh.org/adult/provider/radiology/3DReconstruction/index.html) These are some nice 3D anatomy modules developed by Brian Mullen • LUMEN crossectional anatomy project (http://www.lumen.luc.edu/lumen/meded/grossanatomy/x_sec/mainx_sec.htm) using CT and the Visible Human Project from Loyola University • Brigham Rad (http://brighamrad.harvard.edu/education.html) Casefiles and “Find the Path” – interactive imaging algorithms for common ER presentations. Several cardiac and nuclear medicine tutorials. • Radiological anatomy from McGill University (http://sprojects.mmi.mcgill.ca/radiology/). Basic plain film and cross-sectional anatomy for students • Radlabs from Harvard Medical School (http://mycourses.med.harvard.edu/ocw_rbview.asp? course=RD501M%2E23). Interactive review of basic radiological anatomy for medical students (Kitt Shaffer 50
  • 51. NMSCR 1/30/2015 • Albert Einstein radiology education site (www.learningradiology.com) - Albert Einstein Medical Center Radiology teaching resources and tutorials, cases aimed at medical students and radiology residents-in-training with a very good section for students 2.3. General information and Portals • AMSER (http://www.aur.org/amser/) Alliance of Medical Student Educators in Radiology is a affiliate of the Association of University Radiologists and a excellent resource for medical student program directors in radiology • AMSER discussion board (http://groups.yahoo.com/group/AMSER) • Aunt Minnie.com (http://www.auntminnie.com) General radiology news, cases, well used med student discussion board. Good if you hear about some new radiology test/news and want the inside story on it before your patients ask you.... • Association of Program Directors in Radiology (http://www.apdr.org/edu_portal.htm) Includes information for medical students, teaching resources and program information • RSNA (http://www.rsna.org) Portal for all of radiology, including links for medical students interested in a career in Radiology. Includes a Medical Student Resources Link and an Educational Resources Link • Radiology Education (http://www.radiologyeducation.com/) Multiple links to a huge number of websites, lists textbooks and case files. • Medicalstudent.com (http://www.medicalstudent.com This is an extensive site with current links to all areas of medicine including radiology. This site has won several awards • Medical Education Resources (http://www.meduniv.lviv.ua/inform/studlinks.html) This is another very large collection of links for medical students with many international sites included • Americal College of Radiology (http://www.acr.org/frames/f-residents.html) This is a helpful list of links for radiology residency programs 3. CDROM based programs • Interactive Atlas of Clinical Anatomy (Frank H. Netter, MD) • Introduction to Clinical Imaging (Henry I. Goldberg MD) • Radiologic Anatomy (Linda Lanier, MD) • Skeletal Radiology (Felix S. Chew, MD) • ACR Chest Teaching File • ARCOG Interactive OB U/S • CD Roentgen (Michael P. McDermott, MD) • Essentials of Radiology (Judith Korek Amorosa, MD) 51
  • 52. NMSCR 1/30/2015 4. Textbooks • Squire’s Fundamentals of Radiology ( Novelline 2004) • Essential Radiology (Gunderman 1997) • Felson’s Principles of Roentgeology, A programmed text (Goodman 1999) • Basic Radiology (Chen 2004) • Practical Pediatric Imaging (Kirks 1998) • Fundamentals of Pediatric Radiology (Donnelly 2001) 52
  • 53. NMSCR 1/30/2015 Diagnostic Shortlist : The “Must See” Images Images all students should recognize This is a limited list of diagnoses and their respective imaging modalities that all students should be able to recognize, regardless of their planned speciality. An image set based on this list could be developed by AMSER as a shared resource. Condition Details Modalities Pneumothorax Upright, supine, signs of tension, adult and child CXR, CT Pneumomediastinum CXR, CT Pneumoperitoneum Upright, supine CXR, KUB, CT Pleural effusion Upright, supine CXR, CT Pulmonary edema P.venous hypertension, interstitial, alveolar CXR Aortic dissection CXR, CT Aortic rupture CXR, CT Diaphragmatic rupture KUB, CT SBO Upright, supine KUB Cecal and sigmoid volvulus KUB, enema Distal large bowel obstruction Upright, supine Ascites US, CT Missed placed lines/tubes Dobhoff/NG tubes, central venous catheters, endotracheal tubes CXR, KUB Child abuse Metaphyseal and rib fractures, bilateral subdurals (inc. isodense) CXR, extremity films, CT/MR Stroke Edema, hemorrhage, mass effect CT Intracranial traumatic hemorrhage Epidural, subdural, subarachnoid, intraparenchymal CT Increased intracranial pressure Inc. shift and cerebral herniation, hydrocephalus CT Space occupying lesions Mass effect, +/- contrast CT, MR Cervical spine injury Abnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury Plain films Fracture with extension into joint Plain films Elbow joint effusion Radial head fracture, distal humneral fracture Plain films Shoulder dislocation Plain films 53
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