Radiological Tests: Which One is Most Appropriate for My Patient?

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Hilary Garrison
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1 Radiological Tests: Which One is Most Appropriate for My Patient? Robert Hartman, M.D MFMER slide-1

2 Disclosures No Disclosures 2016 MFMER slide-2

3 Objectives Discuss tools to aid in the ordering of Radiology examinations Radiologist ACR appropriateness criteria Review case vignettes of common situations 2016 MFMER slide-3

4 Choosing the Correct Imaging Protocol Complete information often available for the radiologist Patient presenting to acute care or ED 45-year-old male CT without contrast using Training for a marathon Acute onset Renal of Stone left flank Protocol pain History of calcium oxalate renal calculi Afebrile Microscopic hematuria 2016 MFMER slide-4

5 Choosing the Correct Imaging Protocol Complete information often available for the radiologist Patient presenting to acute care or ED 45-year-old male Belly Pain Training for a marathon Acute onset of left flank pain History of calcium oxalate renal calculi Afebrile Microscopic hematuria 2016 MFMER slide-5

6 Find your go-to radiologist Many cases do not require consultation based on clinical experience Radiologists are happy to assist when deciding on the choice of imaging test Appropriate test for definitive information to aid in management Best guess 2016 MFMER slide-6

ACR Appropriateness Criteria Free to access online https://www.

7 ACR Appropriateness Criteria Free to access online -Safety/Appropriateness- Criteria 2016 MFMER slide-7

8 ACR Appropriateness Criteria Evidence based guidelines Assist referring physicians in making the most appropriate imaging or treatment decision Many topics addressed Multiple variants of many diseases 2016 MFMER slide-8

9 ACR Appropriateness Criteria 2016 MFMER slide-9

10 ACR Appropriateness Criteria 2016 MFMER slide-10

11 Case Vignettes 2016 MFMER slide-11

12 Case 1 61-year-old male Emergency department Knocked off bicycle by car Wearing helmet No loss of consciousness Left hip pain No gross deformity on physical exam Catching discomfort when straining against resistance Pain with weight bearing Negative plain films of the hip and pelvis 2016 MFMER slide-12

13 Management? 20% 20% 20% 20% 20% A. CT With Contrast B. MRI Without Contrast C. Tc-99 Bone Scan D. Ultrasound E. CT Without and With Contrast A. B. C. D. E MFMER slide-13

14 ACR Appropriateness Criteria Acute Hip Pain 2016 MFMER slide-14

15 MRI 2016 MFMER slide-15

16 Case 2 54-year-old female Emergency department Acute onset 10/10 epigastric pain Radiating to back Vomiting, non-bloody, non-bilious PMH: GERD (omeprazole) 2016 MFMER slide-16

17 Case 2 Labs Lipase 8200 AST 800 ALT 400 Serum bilirubin MFMER slide-17

18 Management? A. CT With Contrast B. MRI With Contrast C. Ultrasound D. CT Without Contrast E. MRI Without Contrast 20% 20% 20% 20% 20% A. B. C. D. E MFMER slide-18

19 ACR Appropriateness Criteria Acute Pancreatitis 2016 MFMER slide-19

20 US 2016 MFMER slide-20

21 US 2016 MFMER slide-21

22 Case 3 64-year-old male No meds Positive family history of CAD (Father 63) No history of angina No congestive heart failure No cardiac rhythm disturbance 2016 MFMER slide-22

23 Case 3 BP 128/78 Labs Cholesterol 208 Triglycerides 72 HDL 45 LDL 125 Non- HDL 163 ASCVD risk = 12.9% Has completed life style changes Reluctant to take statin only if I really need 2016 MFMER slide-23

24 Management? A. CT Angiogram Coronary Arteries B. CT Without Contrast Coronary Calcium C. Tc-99 SPECT Rest and Stress D. US Echocardiography E. MRI Heart with contrast 20% 20% 20% 20% 20% A. B. C. D. E MFMER slide-24

25 ACR Appropriateness Criteria 2016 MFMER slide-25

26 Coronary CT 2016 MFMER slide-26

27 Coronary CTA 2016 MFMER slide-27

Online Risk Calculator https://www.mesanhlbi.

28 Online Risk Calculator MesaRiskScore/RiskScore.aspx 2016 MFMER slide-28

29 Case 4 72-year-old female Emergency department Black stools Some orthostatic hypotension Anemia Negative colonoscopy 1 year ago Negative upper endoscopy at local ED 2016 MFMER slide-29

30 Management? A. CT Without Contrast B. CT Enterography C. Tc-99 labeled RBC scan D. Ultrasound E. MRI With Contrast 20% 20% 20% 20% 20% A. B. C. D. E MFMER slide-30

31 ACR Appropriateness Criteria 2016 MFMER slide-31

32 CT Enterography (triple phase) 2016 MFMER slide-32

33 Case 5 46-year-old female Executive health physical Family history of breast cancer Dense breast on mammography Breast MRI Partially imaged liver lesion US Indeterminate > 1cm lesion right hepatic lobe 2016 MFMER slide-33

34 Case 5 Occasional alcohol Never smoker No other health problems No medications 2016 MFMER slide-34

35 Management? A. CT Without Contrast B. MRI Without and With Contrast C. Tc-99 Sulfur Colloid Liver Scan D. FDG PET/CT E. Percutaneous biopsy 20% 20% 20% 20% 20% A. B. C. D. E MFMER slide-35

36 ACR Appropriateness Criteria 2016 MFMER slide-36

37 ACR Appropriateness Criteria 2016 MFMER slide-37

38 MRI (Eovist ) 2016 MFMER slide-38

39 MRI (Eovist ) 10 min 20 min 2016 MFMER slide-39

40 Case 6 29-year-old male Neurology clinic Chronic neck pain Acute onset of right shoulder weakness No trauma No malignancy 2016 MFMER slide-40

41 Case 6 Upper extremities, -1 weakness on the Mayo scale (4/5 on the MRC scale) involving the deltoid, triceps, finger extensors on the right side Subjective cape-like-distribution numbness that extends from the base of his neck down to about the upper thoracic level Negative C-Spine x-ray 2016 MFMER slide-41

42 Management? A. MRI Without and With Contrast B. MRI Without Contrast C. CT Without Contrast D. CT With Contrast E. Tc-99 bone scan 20% 20% 20% 20% 20% A. B. C. D. E MFMER slide-42

43 ACR Appropriateness Criteria Chronic Neck Pain 2016 MFMER slide-43

44 ACR Appropriateness Criteria Chronic Neck Pain 2016 MFMER slide-44

45 MRI C-Spine 2016 MFMER slide-45

46 Summary Radiology imaging is increasingly useful Increasingly complex to know where to start Radiologists can be a useful tool Knowledge of which exam is best starting point Know strengths of particular practice ACR Appropriateness criteria Imaging choice When imaging not necessary 2016 MFMER slide-46

47 Thank You 2016 MFMER slide-47

PREAMBLE GENERAL DIAGNOSTIC RADIOLOGY

PREAMBLE GENERAL DIAGNOSTIC RADIOLOGY PREAMBLE The General Diagnostic Radiology category is intended to cover the body of knowledge a practicing board certified Diagnostic Radiologist should know. Since the range of content relevant to the