Contributors. Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous contribution of images:

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Contributors Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous contribution of images: Peter Miller, MD, Indiana University School of Medicine Chapter 1:

1 Contributors Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous contribution of images: Peter Miller, MD, Indiana University School of Medicine Chapter 1: Figure 1-3 Chapter 2: Figures 2-5, 2-12, 2-14, 2-28, 2-33, 2-36, 2-43, 2-47, 2-65, 2-67, 2-70, 2-76, 2-78 Chapter 3: Figures 3-3, 3-4, 3-5, 3-6, 3-7, 3-9, 3-11, 3-12, 3-28, 3-29 Chapter 4: Figures 4-1, 4-4, 4-5, 4-6, 4-7, 4-11, 4-13, 4-16, 4-18, 4-19, 4-20, 4-29, 4-33 Chapter 5: Figures 5-6, 5-13, 5-15, 5-17, 5-18, 5-19, 5-21, 5-22, 5-23, 5-24, 5-29, 5-30, 5-31, 5-33 Chapter 6: Figures 6-25, 6-43, 6-44 Chapter 8: Figures 8-1, 8-2, 8-3, 8-4, 8-6, 8-7, 8-9, 8-10, 8-11, 8-12, 8-13 Chapter 9: Figures 9-1, 9-2, 9-3, 9-4, 9-5, 9-10, 9-11, 9-17, 9-22, 9-24, 9-26, 9-27, 9-28, 9-29, 9-32 Chapter 10: Figures 10-15, 10-16, LCDR Kevin Preston, MD, Indiana University School of Medicine Chapter 2: Figures 2-35, 2-38, 2-39, 2-40, 2-41, 2-45, 2-56, 2-63, 2-79, 2-81, 2-83, 2-84 Chapter 6: Figures 6-5, 6-7, 6-12, 6-14, 6-18, 6-19, 6-21, 6-22, 6-23 Chapter 8: Figures 8-18, 8-20 Keith Newbrough, MD, Indiana University School of Medicine Chapter 2: Figures 2-8, 2-9, 2-18, 2-29 Chapter 6: Figure 6-17 Chapter 7: Figure 7-5 viii

2 Reviewers Linda G. Allison, MD, MPH Associate Professor, Pharmacy Practice Belmont University School of Pharmacy Nashville, Tennessee Jesse A. Coale, PA-C Assistant Professor Physician Assistant Studies College of Science, Health & the Liberal Arts Philadelphia University Philadelphia, Pennsylvania Randy Danielsen, PhD, PA-C Senior Vice-President National Commission on Certification of Physician Assistants Foundation Johns Creek, Georgia Steve B. Fisher, MHA, PA-C Senior Surgical Physician Assistant Department of Neurosurgery, Kentucky Neuroscience Institute University of Kentucky Lexington Kentucky Charlene Morris, MPAS, PA-C, DFAAPA Family Medicine Pamlico Medical Center, PA Bayboro, North Carolina ix

3 Chapter 1: Modalities of Medical Imaging 1 RADIOGRAPHY 1 Radiographic Densities 1 Types of Resolution 2 Radiographic Projections 3 PA/AP Views 3 Lateral Views 4 Oblique Views 4 Viewing Radiographic Projections 5 CROSS-SECTIONAL IMAGING, TOMOGRAPHY, AND BODY PLANES 7 COMPUTED TOMOGRAPHY: CROSS-SECTIONAL IMAGES AND RECONSTRUCTIONS 7 MAGNETIC RESONANCE IMAGING 11 ULTRASOUND 12 NUCLEAR MEDICINE 14 INTERVENTIONAL RADIOLOGY 15 STRENGTHS AND WEAKNESSES OF IMAGING MODALITIES 16 CONTRAST ENHANCEMENT 16 THE RADIOLOGY WORKSTATION AND PACS SYSTEMS 17 THE RADIOLOGY REQUISITION AND THE RADIOLOGY REPORT 18 HOW SAFE IS MEDICAL IMAGING? 19 Chapter Review Questions 20 Chapter 2: Shoulder, Pelvis, and Limbs 21 EXTREMITIES 21 FUNDAMENTALS OF MUSCULOSKELETAL IMAGING 21 SHOULDER AND ARM 23 Trauma and Acute Pain 23 Modalities 23 Interpretation 25 Chronic Conditions of the Shoulder Including Soft Tissue Masses 27 Modalities 27 Interpretation 28 ELBOW AND FOREARM 30 Trauma and Acute Pain 30 Modalities 30 Interpretation 30 Chronic Conditions of the Elbow 32 Modalities 32 Interpretation 32 WRIST AND HAND 33 Acute Pain and Trauma 33 Modalities 33 Interpretation 33 Chronic Conditions Including Soft Tissue Masses 36 Modalities 36 Interpretation 36 PELVIS, HIP, AND THIGH 37 Trauma and Acute Pain 37 Modalities 37 Interpretation 37 Chronic Conditions Including Soft Tissue Masses 38 Modalities 39 Interpretation 40 KNEE AND LOWER LEG 41 Acute Pain and Trauma 41 Modalities 41 Interpretation 42 Chronic Knee and Lower Leg Pain 47 Modalities 47 Interpretation 47 ANKLE AND FOOT 49 Acute Pain and Trauma 49 Modalities 49 Interpretation 50 Chronic Ankle and Foot Pain 54 Modalities 54 Interpretation 55 LOWER LIMB VASCULAR DISEASE: PERIPHERAL ARTERIAL INSUFFICIENCY AND VENOUS THROMBOSIS 57 Modalities 57 Interpretation 57 Chapter Review Questions 60 Chapter 3: Spine and Spinal Cord 65 FUNDAMENTALS OF SPINE AND SPINAL CORD IMAGING 65 SPINAL TRAUMA 65 Modalities 66 Interpretation 66 Cervical Spine 66 Thoracolumbar Spine 68 xi

4 xii NECK AND BACK PAIN (No Neurologic Signs or Symptoms) 70 Modalities 70 Interpretation 72 Cervical Spine 72 Thoracolumbar Spine 73 NECK OR BACK PAIN WITH RADICULOPATHY OR MYELOPATHY 77 Modalities 77 Interpretation 78 Chapter Review Questions 82 Chapter 4: Brain 85 FUNDAMENTALS OF BRAIN IMAGING 85 TRAUMA 85 Modalities 85 Interpretation 85 ACUTE NON-TRAUMA NEUROLOGIC EMERGENCY (Stroke and Hemorrhage) 87 Modalities 87 Interpretation 88 HEADACHE 90 Modalities 90 Chronic Headache 91 Recent Onset or Change in Character of Headache 91 With Other Neurologic Symptoms and Signs 91 INTERPRETATION 91 With Signs of Meningeal Irritation 93 INTERPRETATION 93 In the Pregnant Patient 93 INTERPRETATION 94 Unilateral Headache 94 MODALITIES 94 INTERPRETATION 94 MOVEMENT DISORDERS 94 Modalities 95 Interpretation 95 FOCAL NEUROLOGIC DYSFUNCTION 95 Modalities 96 Interpretation 96 NEUROENDOCRINE DYSFUNCTION 98 Modalities 98 Interpretation 98 EPILEPSY AND SEIZURES 98 Modalities 99 Interpretation 99 DEMENTIA 100 Modalities 100 Interpretation 100 Chapter Review Questions 102 Chapter 5: EENT Imaging 105 FUNDAMENTALS OF EYES, EAR, NOSE, AND THROAT IMAGING 105 NASAL CONGESTION AND SINUSITIS 105 Modalities 105 Interpretation 105 NECK LUMPS 107 Modalities 108 Interpretation 108 FACIAL DROOP (Bell s Palsy) 111 Modalities 111 Interpretation 112 DYSPHAGIA AND SORE THROAT 112 Modalities 112 Interpretation 113 VISUAL PROBLEMS 113 Modalities 114 Interpretation 115 HEARING PROBLEMS 115 Modalities 116 Interpretation 116 VERTIGO AND TINNITUS 116 Modalities 117 Interpretation 117 FACIAL TRAUMA AND TEMPOROMANDIBULAR JOINT (TMJ) 117 Modalities 117 Interpretation 117 CAROTID ARTERY DISEASE 119 Modalities 119 Interpretation 119 Chapter Review Questions 122 Chapter 6: Chest 125 FUNDAMENTALS OF CHEST RADIOGRAPHY 125 ROUTINE CHEST RADIOGRAPHY 125 Technique 125 Interpretation 126 TRAUMA 131 Modalities 131 Interpretation 132 DYSPNEA 134 Modalities 134 Interpretation 135 HEMOPTYSIS 138 Modalities 139 Interpretation 139 NON-TRAUMATIC CHEST WALL AND PLEURITIC PAIN 140 Modalities 140 Interpretation 140

5 xiii CARDIAC DISEASE: GENERAL CONSIDERATIONS 141 Modalities 141 Interpretation 142 ACUTE CHEST PAIN 143 Modalities 143 Interpretation 144 CHRONIC CHEST PAIN 144 Modalities 144 Interpretation 145 CONGESTIVE HEART FAILURE 145 Modalities 145 Interpretation 145 Chapter Review Questions 147 Chapter 7: Breast 151 FUNDAMENTALS OF BREAST IMAGING 151 BREAST CANCER SCREENING 151 The Screening Mammogram 152 Modalities 152 Interpretation 153 THE PALPABLE BREAST MASS OR POSITIVE FINDINGS ON SCREENING MAMMOGRAPHY 154 Modalities 156 Interpretation 156 BREAST CANCER SCREENING IN THE HIGH-RISK PATIENT 159 Modalities 159 Interpretation 160 Chapter Review Questions 161 Chapter 8: Abdomen 163 FUNDAMENTALS OF ABDOMINAL IMAGING 163 TRAUMA 163 Modalities 163 Interpretation 164 ABDOMINAL PAIN 164 Modalities 164 Interpretation 166 JAUNDICE 172 Modalities 172 Interpretation 172 GI BLEEDING 173 Modalities 173 Interpretation 174 NON-SPECIFIC ISSUES, SUCH AS WEIGHT LOSS, VOMITING, AND ABNORMAL LABORATORY STUDIES 174 Modalities 174 Interpretation 176 Chapter Review Questions 179 Chapter 9: Male and Female Urinary Tract and Male Genital Tract 181 FUNDAMENTALS OF IMAGING THE MALE AND FEMALE URINARY TRACT AND MALE GENITAL TRACT 181 TRAUMA 181 Modalities 181 Interpretation 182 SUSPECTED RENOVASCULAR HYPERTENSION 183 Modalities 183 Interpretation 183 ACUTE ONSET FLANK PAIN 184 Modalities 184 Interpretation 185 ACUTE SCROTAL PAIN AND SCROTAL MASSES 186 Modalities 186 Interpretation 186 HEMATURIA AND RENAL MASSES 188 Modalities 188 Interpretation 188 DIFFICULTY VOIDING 191 Modalities 191 Interpretation 191 URINARY TRACT INFECTION 192 Modalities 192 Interpretation 192 RENAL FAILURE/INSUFFICIENCY 194 Modalities 194 Interpretation 194 THE PROSTATE GLAND 194 Modalities 194 Interpretation 195 Chapter Review Questions 196 Chapter 10: Female Pelvic Imaging 199 FUNDAMENTALS OF FEMALE PELVIC IMAGING 199 FERTILITY IMAGING 200 Modalities 200 Interpretation 200 OBSTETRIC IMAGING 201 Modalities 202 Interpretation 202 ACUTE PELVIC PAIN IN PATIENTS OF REPRODUCTIVE AGE 205 Modalities 205 Interpretation 206 The Pregnant Patient 206 The Non-pregnant Patient 206

6 xiv IMAGING OF ABNORMAL VAGINAL BLEEDING AND PELVIC MASSES 208 Modalities 208 Interpretation 208 Chapter Review Questions 212 Chapter 11: Imaging of Bone Disease and Endocrine Disorders. 215 FUNDAMENTALS OF IMAGING OF BONE DISEASE AND ENDOCRINE DISORDERS 215 OSTEOPOROSIS AND PAGET DISEASE 215 Modalities 215 Interpretation 216 THYROID AND PARATHYROID DYSFUNCTION 217 Modalities 218 Interpretation 218 ADRENAL DYSFUNCTION AND NEUROENDOCRINE TUMORS OF THE PANCREAS 219 Modalities 219 Interpretation 220 PITUITARY DYSFUNCTION 220 Modalities 221 Interpretation 221 Chapter Review Questions 222 Chapter 12: Clinical Practice Issues in Medical Imaging 223 INCIDENTALOMAS 223 Incidental Findings on Chest CT 224 Incidental Hepatic Lesions 224 Incidental Pancreatic Cysts 224 Incidental Adrenal Masses 224 Incidental Renal Masses 224 Incidental Bone Findings 225 Incidental Thyroid Nodules 225 THE AMERICAN COLLEGE OF RADIOLOGY ACR APPROPRIATENESS CRITERIA 225 TALKING TO PATIENTS ABOUT THE RISKS OF IMAGING PROCEDURES 225 CLAUSTROPHOBIA AND MRI 228 COMMUNICATION AND COLLABORATION AMONG MEDICAL PROFESSIONALS 228 QUALITY PATIENT CARE IN IMAGING 229 Appendix A: Glossary 231 Appendix B: Answers to Chapter Review Questions 235 Index 237

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