AUGUST 25-27, 2017 UPDATE & BOARD REVIEW. acofp INTENSIVE. Decision Points in Diagnostic Testing: A Review for Family Medicine Physicians

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1 acofp INTENSIVE UPDATE & BOARD REVIEW AUGUST 25-27, 2017 Loews Chicago O'Hare Hotel Rosemont, IL INNOVATIVE COMPREHENSIVE HANDS-ON Decision Points in Diagnostic Testing: A Review for Family Medicine Physicians Christine D. Martino, DO acofp Am eric an College of Osteopathi c Family Physicians The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

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3 Decision Points in Diagnostic Testing: A Review for Family Medicine Physicians U S I N G T H E A M E R I C A N C O L L E G E O F R A D I O L O G Y A P P R O P R I A T E N E S S C R I T E R I A F O R C L I N I C A L D E C I S I O N M A K I N G I N O R D E R I N G I M A G I N G S T U D I E S C H R I S T I N E M A R T I N O, D. O. A R I A J E F F E R S O N H E A L T H F A M I L Y M E D I C I N E F A M I L Y M E D I C I N E / E M E R G E N C Y M E D I C I N E R E S I D E N C Y F A C U L T Y Disclosure I have no financial relationship or interest in any proprietary entity producing health care goods or services. The content of my material will not include discussion of unapproved or investigational uses of products or devices. What Do Family Doctors Say? 73% feel that ordering unnecessary tests and procedures is a problem 47% patients ask for an unnecessary test or procedure at least once a week 53% will order a test or procedure even if they know it is not necessary 70% patients will avoid an unnecessary test or procedure if it is explained to them. 1

4 What radiology study do I order next? 2017 ACR Appropriateness Criteria Evidence based guidelines Assist physicians in making the most appropriate imaging decisions Reviewed annually 230 clinical topics and 1100 variants TOPIC OVERVIEW Neuro Headache Vertigo Neck mass/adenopathy Breast Pain Mass Musculoskeletal Soft tissue mass Acute low back pain GI LLQ pain RLQ pain RUQ pain Dysphagia Liver lesion SBO Urologic Flank pain Scrotal pain Hematuria Incidental adrenal/renal mass 2

5 NEUROLOGY HEADACHE Case 1 Anne is a 41 year old female with past history of migraine without aura who presents to the office with 3 day history of severe headache and a tingling sensation on the left side of her face. No associated vision changes, confusion, slurred speech. She is a business executive and has had increased stress at work over the last several weeks. Vital signs are normal PE: slight reduced sensation on the left face, arm and leg What imaging would you consider? 3

6 Decision Point 1 WITH or WITHOUT neurologic deficits If YES Imaging If NO no Imaging Decision Point 2 Headache PLUS neurologic symptom Imaging WHAT IMAGING? If emergent CT WITHOUT contrast If non-emergent MRI WITH & WITHOUT contrast Case 1 MRI with and without contrast 4

7 WITH contrast Detailed images Neovascularity/hypervascularity Tumors +and+without+contrast&oq=mri+brain+with+and+&gs_l=psyab.3.0.0j0i24k1l j psyab i67k1j0i8i30k1.uzxhk16xbxa#imgrc=x4dhlvqatdoybm: NEUROLOGY VERTIGO Case 2 45 year old female presents with acute onset of dizziness described as a room spinning sensation. She has had some vomiting during this time. Symptoms have been intermittent for 3 days. There is associated hearing loss. VS are normal PE: neurologic exam peripheral nystagmus Do you order imaging? 5

8 Who to Image? Those who have history of benign vertigo DO NOT usually need imaging Consider in those who: Have asymmetric hearing loss Unusual features Neuro signs What to Order for Vertigo? MRI WITH contrast Consider CT (superior) if temporal bone fracture suspected Consider MRA or CTA if vertebral artery dissection is a concern Imaging not helpful in looking at specific causes of vertigo (i.e. Meniere s disease) Helpful in NEOPLASM and VASCULAR and INFECTIOUS NEUROLOGY HEAD AND NECK MASS/ADENOPATHY 6

9 Case 3 52 year old male with history of tobacco use presents with painless swelling on the right neck. He has no fever. VS are normal. PE: firm immobile mass (estimated at 2 cm) on right anterior neck What to order? Overview of Neck Masses 20 years and under: favors benign 20-40: usually malignant 40 years and older (especially + tobacco): overwhelmingly malignant What to Order? CT and MRI have equal sensitivity/specificity WITH contrast Delineates tumor margins Abscesses (essential) NONCONTRAST CT for suspected salivary gland obstruction by siaololith Avoid iodine based contrast in those with previous thyroid cancer or if metastatic thyroid cancer is suspected US can be used Best for biopsy of small masses/superficial masses Staging of lymph nodes Delineating solid vs cystic mass 7

10 BREAST PAINFUL BREAST ed=0ahukewjfrsfg59btahukzomkhzoaboeq_auicigb&biw=1920&bih= 950#tbm=isch&q=breast+mammo&imgrc=rE1-d0UZEXWHVM Case 4 30 yo female with normal menstrual cycles complains of bilateral breast tenderness that can fluctuate along with her menstrual cycle. She describes pinching and razor-like sensations diffusely. No fevers or other associated symptoms. VS: normal PE: no breast mass/nipple discharge What study to order? Overview Mastalgia 70 80% women will experience in lifetime Etiology is not well understood and is likely multifactorial Hormones, meds (SSRI), +/- caffeine Cyclical vs noncyclical Marker for cancer? One study found 2-3.6% increased relative risk Or is it that women who have very dense breasts have more pain and dense breasts has recently been tied to cancer? 8

11 What to order? Cyclical and bilateral pain no imaging Noncyclical and unilateral pain imaging 30 years and younger: US years: US + mammo 40+: Mammo No data to support MRI in breast pain workup BREAST BREAST MASS ed=0ahukewjfrsfg59btahukzomkhzoaboeq_auicigb&biw=1920&bih= 950#tbm=isch&q=breast+mammo&imgrc=rE1-d0UZEXWHVM Case 5 44 yo female mentions that she felt a lump in her left breast last week. She is concerned it may be cancer. VS: normal PE: left breast with freely mobile 2 cm mass at 6 o clock 9

12 Overview Breast Mass Cysts can not accurately be differentiated from solid masses by palpation One study found only 58% of lesions were correctly identified as cysts (n=66) Negative predictive value of mammo plus US = % 40 yo Female with palpable mass, initial test Diagnostic mammogram NO role for MRI with or without contrast MRI can differentiate scar vs lesion in later f/u testing 40 yo female with suspicious mammo finding US ordered next 10

13 30 yo female with palpable mass US If suspicious proceed directly to biopsy Can also add mammo at that time No indication for short term f/u. Next step is tissue sampling. If lesion is benign on US Short interval f/u +/- mamo Summary of Recommendations Clinical examinations are inconsistent all lumps should be imaged Diagnostic mammo if 40+ years old US if less than 30 years old Diagnostic mammo OR US if years old Any highly suspicious mass found on imaging should be biopsied Any highly suspicious palpable mass should be biopsied Any age female with mass not visualized on mammo Proceed with tissue sampling 11

14 GI DYSPHAGIA Case 6 90 year old male recently hospitalized after a TIA. He is in the office to discuss medication changes and recent dietary modifications. He wonders what is appropriate to eat. VS: normal PE: frail male in NAD, lungs clear Overview Dysphagia can be due to structural or functional causes Thyroid fullness, neurologic, mass, esophageal web, oropharyngeal, hiatal hernia, reflux Fluoroscopic studies are the modalities of choice 12

15 What to order? Modified barium swallow Videofluoroscopic study with a speech therapist Oral cavity, pharynx, cervical esophagus Use of various barium consistencies NEURO Esophagram Looks at whole esophagus Can evaluate webs, mass, hiatal hernia, reflux GI LLQ PAIN Case 7 Mr. L is 58 years old and is in the office complaining of LLQ pain for 2 days. It is sharp and worse when he eats. VS: normal PE: TTP to LLQ but abdomen is soft without rigidity 13

16 Overview Likely will not need imaging in the patient with clinical diverticulitis and no complications Imaging will help find Abscesses Fistulas Obstruction Perforation What to order? CT with IV and PO contrast Can also identify mimickers of diverticulitis US is a poor choice Does not identify perforated viscus GI RLQ PAIN 14

17 Case 8 5 year old boy presents to the family doctor with slight fever, anorexia and poorly localized abdominal pain. He has decreased energy and is obviously in discomfort during the exam. VS: Temp F, otherwise normal PE: TTP to RLQ What to order next? Overview Most common cause to identify with imaging is appendicitis Consider pelvic organs in females Consider elderly patients AAA Dissection In cases where clinical suspicion is very high, no imaging is necessary and the next step is to proceed directly to surgery. What to Order? CT is the most accurate imaging study WITH IV contrast PO or rectal contrast? What about US? CT demonstrates superiority US is great for peds Dependent upon operator skill US followed by CT in unclear cases Pregnant females MRI Pediatric patients US 15

18 GI LIVER LESION Case 9 47 yo female with no PMH had RUQ pain and discomfort after eating. A RUQ US was obtained. It showed cholelithiasis. Incidentally a 0.6 cm cystic structure was found in the liver. Further imaging to characterize the lesion was recommended. What to order? Overview Benign liver lesions are frequent incidentolomas that create confusion for f/u Common benign lesions: Cysts Biliary hamartomas Hemangiomas Also non-tumor lesions Fat Abscess Hematomas Vascular shunts 16

19 What to Order? MRI without and with contrast is the technique of choice If contrast is contraindicated opt for without CT with contrast is the next optional test If there is a survey of the entire body needed (pt with cancer for staging) CT with contrast is the study of choice CT without contrast has very little role in characterizing liver lesions and should not be used US also has limitations But can distinguish cystic vs solid lesions GI R U Q P A I N Case 10 Katherine is a 45 year old overweight female who has pain in the right upper abdomen that occurs after eating. She states the attacks last for several hours. No vomiting, fever, changes in bowels. VS: afebrile PE: ttp to the right upper quadrant, normal BS, soft, no guarding 17

20 Overview Typically we are looking for acute cholecystitis It can be a life threatening disease and needs to be diagnosed quickly What to Order? US and cholescintigraphy No role for abdominal xrays Sonographic Murphy sign has low specificity and its absence is unreliable as a negative predictor of disease Musculoskeletal SOFT TISSUE MASS 18

21 Case year old female presents with a soft mobile lesion on the right arm that has been present for approximately 3 years. Lately it seems to be more bothersome and she is wondering if it has been growing. VS: normal PE: 4 cm soft tissue mass, freely mobile, located on the right forearm, mildly tender, normal surrounding skin Overview Lesions may be painless or painful Often felt by patient or physician Imaging should be done before biopsy Some sarcomas may be in the bone What to Order? MRI is the most optimal study With contrast May need more advanced techniques to distinguish between benign and malignant Consider CT for Patients with pacemakers Abdominal wall masses where motion artifact makes MRI suboptimal US to identify lipomas/cysts/lymph nodes X-ray for bony pain to evaluate for sarcoma or other bony mass 19

22 Musculoskeletal ACUTE LOW BACK PAIN Case yo male with hx of obesity presents with one week of pain in the lumbosacral region. Tends to improve with rest. No obvious trauma although he was moving boxes with a friend a few days prior to the onset of pain. No radiculopathy, fever, hx malignancy. VS: normal PE: spasm and ttp to the lumbosacral muscles, 5/5 strength in b/l LE Overview 0-6 weeks 3 categories 1. Nonspecific LBP 2. LBP possibly associated with spinal stenosis or radiculopathy 3. LBP associated with another specific cause Emphasis on reassurance, good physical exam and physical therapy WITHOUT imaging If uncomplicated without warning signs Imaging is warranted for: Warning signs Elderly No change in symptoms after 6 weeks of supportive care, meds, PT 20

23 What to Order? X-rays ankylosing spondylitis Trauma Possible vertebral compression fractures May consider proceeding directly to MRI After 6 weeks of conservative therapy Warning signs If history of cancer MRI with contrast Urologic A C U T E F L A N K P A I N Case year old female presents with 1 day history of waxing and waning right flank pain. Pain can approach 10/10. VS: hypertensive PE: obvious discomfort, right flank ttp 21

24 Overview A stone < 5 mm has a 68% chance of passing spontaneously The usual go-to test is noncontrast CT Has significant radiation exposure What to Order? CT without contrast is study of choice US is sensitive (60-90%) but if a stone is missed it will not be clinically significant. US is 100% sensitive at detecting ureter obstruction Which is what we care about KUB alone not a good test to order KUB + US is an option Urologic S C R O T A L P A I N 22

25 Case year old male presents with 2 hours of intense testicular pain. VS: hypertensive, pale PE: ttp of the right scrotum, swelling of the right scrotum Overview Important to distinguish between surgical and nonsurgical causes; emergent causes Torsion Epididymitis Tumor Torsion is rare in those older than 35 yo Negative UA, sudden onset Epididymitis very common in those older than 25 yo Positive UA, gradual in onset US can obviate the need for surgical exploration What to Order? US WITH Doppler Color Doppler has sensitivity of % 23

26 Urologic H E M A T U R I A Case year old female presents for routine preemployment physical and is found to have microscopic hematuria on her UA. She denies UTI symptoms. VS: normal PE: normal Overview Microscopic hematuria is 3+ RBC/HPF Patients with no disease may release blood cells and there may be trace blood in UA However there is no threshold that separates disease from normal results Stones, infection, tumor Typically will order imaging and cystoscopy 24

27 What to Order? US or CT US has lower sensitivity but may be useful as first line CT urogram Urologic I N C I D E N T A L A D R E N A L M A S S Case yo female found to have incidental mass on the left adrenal gland when she had recent CT imaging for acute abdominal pain. She was told to f/u with her PCP. VS: normal PE: normal abdomen/flank exam, normal UA. 25

28 Overview The incidentaloma Majority are benign and adenomas Prevalence in general population is 1-2% On autopsy found to be has high as 4% The risk of adrenal carcinoma in general population is 0.06% Increases to 4.7% among those with an adrenal mass Gajraj H, Young AE. Adrenal incidentaloma. Br J Surg. 1993;80(4): Overview Size 4 cm Features Fat is good functional? Stability If stable over one year, no further imaging is required What to Order? CT noncontrast MRI US can not determine malignancy vs benign features if lesion under 3 cm If known cancer, proceed to PET scan. 26

29 Non-Contrast vs Contrast CT Non-Contrast CT Spine Extremity Head trauma Stroke Lung +/- renal stones Contrast CT Appendicitis Diverticulitis Abscess PE TOPIC OVERVIEW Neuro Headache Vertigo Neck mass/adenopathy Breast Pain Mass Musculoskeletal Soft tissue mass Acute low back pain GI LLQ pain RLQ pain RUQ pain Dysphagia Liver lesion SBO Urologic Flank pain Scrotal pain Hematuria Incidental adrenal/renal mass References American College of Radiology American Academy of Family Physicians American Family Physician Charts/Tables References on the slide 27