Student Curriculum

NMSCR 11/19/2010 1

AMSER

National Medical Student Curriculum in Radiology

Edited by:

Petra Lewis M.D. Kitt Shaffer M.D.

Updated 7/6/09

NMSCR 11/19/2010 2

Table of Contents

Table of Contents ........................................................................................................... 2

Key Concepts ................................................................................................................ 13

Aim ........................................................................................................................................ 13

Philosophy behind a student rather than resident based curriculum in Radiology. .................. 13

General concepts about the medical student curriculum in radiology ..................................... 13

Curricular Framework ................................................................................................... 14

Core radiology topics ............................................................................................................. 14

Detailed organ-based curriculae ............................................................................................. 14

Curriculum resources ............................................................................................................. 15 Websites ........................................................................................................................................................................ 15 CDROM based programs ................................................................................................................................................ 15 Textbooks ....................................................................................................................................................................... 15

Diagnostic short-list ............................................................................................................... 15

Goals and Objectives .............................................................................................................. 16

AMSER Shared Resources ....................................................................................................... 16

Radiology ExamWeb .............................................................................................................. 16

Core Topics ................................................................................................................... 17

1. Physics concepts important to the clinician ......................................................... 17

What produces density differences on radiographs ................................................................ 17

Terminology used in radiology ............................................................................................... 17

Silhouette signs on CXR/KUB .................................................................................................. 17

Key modality differences ........................................................................................................ 17

2. Limitations of modalities ..................................................................................... 17

3. Contrast media ................................................................................................... 17

Intracavitary: ......................................................................................................................... 18

IV: .......................................................................................................................................... 18

4. Orientation to radiology department ................................................................. 18

Ordering urgent/routine studies ............................................................................................ 18

Getting wet readings .............................................................................................................. 18

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Accessing reports ................................................................................................................... 18

Use of PACS system (specific to individual programs) ............................................................. 18

5. Radiation safety and risks ................................................................................... 19

Risks associated with radiation exposure ............................................................................... 19

CXR equivalents of common examinations ............................................................................ 19

Methods to reduce radiation exposure ................................................................................... 19

Age dependance of radiation sensitivity ................................................................................. 19

6. Imaging in pregnancy and breast feeding ........................................................... 19

Preferred studies ................................................................................................................... 19

Studies that should be performed if absolutely necessary with shielding if possible ................ 20

Contraindicated studies ......................................................................................................... 20

7. Other ‘risks’ of radiology ..................................................................................... 20

Contrast media ...................................................................................................................... 20

Risks of percutaneous biopsies and drainage procedures ........................................................ 20

Claustrophobia ...................................................................................................................... 21

Complications specific to fluoroscopy ..................................................................................... 21

Complications specific to nuclear medicine ............................................................................ 21

Complications specific to MRI................................................................................................. 21

Complications specific to pulmonary angiography .................................................................. 21

False positive and negative studies......................................................................................... 21

8. Financial costs ..................................................................................................... 21

Chest Imaging ............................................................................................................... 23

1. Technical aspects ................................................................................................ 23

Techniques used to image this anatomical/physiological area ................................................ 23 CXR: ................................................................................................................................................................................ 23 CT: .................................................................................................................................................................................. 23 MRI: ................................................................................................................................................................................ 23 Pulmonary angiography: ................................................................................................................................................ 23 Nuclear medicine: .......................................................................................................................................................... 23

Patient preparation and education ......................................................................................... 23

Studies that ideally should be watched during elective period or clinical rotations ................. 23

2. Normal anatomy ................................................................................................. 23

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Structures that should be identified on each modality ............................................................ 23 CXR (PA and lateral) and CT ........................................................................................................................................... 23 Pulmonary angiogram (CT and conventional) and MRI ................................................................................................. 24

3. Pathological conditions ....................................................................................... 24

Common pathological conditions/findings that the student should recognize or at least see examples of: .......................................................................................................................... 24 Atelectasis: ..................................................................................................................................................................... 24 Pneumonia: .................................................................................................................................................................... 24 Vascular abnormalities .................................................................................................................................................. 24 Pleural abnormalities ..................................................................................................................................................... 25 Cardiac abnormalities .................................................................................................................................................... 25 Masses ........................................................................................................................................................................... 25 Adenopathy.................................................................................................................................................................... 25 Interstitial abnormalities................................................................................................................................................ 25 Other .............................................................................................................................................................................. 25

Iatrogenic pathology .............................................................................................................. 25

Emergency “don’t miss” findings (CXR) ................................................................................... 25

Diagnostic situations/conditions that do NOT require imaging ............................................... 26

4. Invasive procedures ............................................................................................ 26

Identify clinical scenarios where image-guided procedures are beneficial ............................... 26

5. Imaging algorithms (appropriateness criteria) .................................................... 26

Appropriate imaging management algorithms for common diagnostic situations ................... 26

Cost-effective imaging ............................................................................................................ 26

Incorporating imaging findings into patient management ....................................................... 27 Effects of pre-test probabilities ..................................................................................................................................... 27

Abdominal Imaging ...................................................................................................... 28


Techniques used to image this anatomical/physiological area ................................................ 28


Studies that should be watched during elective period ........................................................... 28

2. Normal anatomy ................................................................................................. 28

Structures that should be identified on each modality ........................................................... 28


Common pathological conditions/findings that the student should recognize or at least see examples of: .......................................................................................................................... 29 KUB: ............................................................................................................................................................................... 29 Fluoroscopic studies: ..................................................................................................................................................... 29

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Ultrasound: .................................................................................................................................................................... 29

Emergency “don’t miss” findings ............................................................................................ 29

Diagnostic situations/conditions unlikely to benefit from imaging .......................................... 30



5. Imaging management (appropriateness criteria) ................................................ 30

Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging .................................................................................................................................. 30

Incorporating imaging findings into patient management including impact of pre-test probabilities .......................................................................................................................... 30

Musculoskeletal Radiology ........................................................................................... 31


Techniques used to image this anatomical/physiological area ................................................ 31 CT ................................................................................................................................................................................... 31 MR .................................................................................................................................................................................. 31 Fluoroscopy .................................................................................................................................................................... 31 Ultrasound ..................................................................................................................................................................... 31


Studies that should be watched during elective period or clinical rotations ............................ 31

2. Normal anatomy ................................................................................................. 31

Structures that should be identified on each modality) ........................................................... 31


Common pathological conditions/findings that the student should recognize or at least see examples of : ......................................................................................................................... 32 Trauma: .......................................................................................................................................................................... 32 Arthritis: ......................................................................................................................................................................... 33 Tumors: .......................................................................................................................................................................... 33 Metabolic bone disease: ................................................................................................................................................ 33 Infections: ...................................................................................................................................................................... 33




Identify clinical scenarios where image-guided procedures may be beneficial ......................... 33


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Appropriate imaging management algorithms for common diagnostic situations including cost-effective imaging ................................................................................................................... 34

Incorporating imaging findings into patient management including effects of pre-test probabilities .......................................................................................................................... 34

Interventional Radiology .............................................................................................. 35


Techniques used in IR ............................................................................................................. 35 Imaging .......................................................................................................................................................................... 35 Image guided biopsy techniques ................................................................................................................................... 35


Studies that should be watched during elective period or during clinical rotations .................. 35

Diagnostic situations/conditions unlikely to benefit from image guided procedures ............... 35

2. Normal anatomy ................................................................................................. 36



Common pathological conditions/findings that the student should recognize or at least see examples of on diagnostic IR studies during radiology or clinical rotations .............................. 36 Vascular .......................................................................................................................................................................... 36 Non-vascular .................................................................................................................................................................. 36



Identify clinical scenarios where image-guided procedures may be beneficial ......................... 36 Diagnostic studies .......................................................................................................................................................... 36 Biopsy procedures ......................................................................................................................................................... 36 Drainage procedures ...................................................................................................................................................... 36 Angioplasty, direct intravascular thrombolysis and stent placements .......................................................................... 37 Embolization procedures ............................................................................................................................................... 37 Access procedures ......................................................................................................................................................... 37 Others ............................................................................................................................................................................ 37


Appropriate imaging management algorithms for common diagnostic/therapeutic situations including cost-effective imaging ............................................................................................. 37

Emergency Radiology ................................................................................................... 39




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Studies that ideally should be watched during elective period or during clinical rotations ....... 39

2. Normal anatomy ................................................................................................. 39

Structures that should be identified on each modality ............................................................ 39


Common pathological conditions/findings that the student should recognize or at least see examples of during radiology or clinical rotations: .................................................................. 39 Trauma ........................................................................................................................................................................... 39 Non-traumatic ................................................................................................................................................................ 40






5. Imaging algorithms (appropriateness criteria) and cost effective imaging .......... 42

Appropriate imaging algorithms for common diagnostic situations ......................................... 42


Women’s Imaging......................................................................................................... 43


Techniques used to image this anatomical/physiological area ................................................ 43 Mammography (analogue, digital) ................................................................................................................................ 43 Ultrasound ..................................................................................................................................................................... 43 Hysterosalpingograms ................................................................................................................................................... 43 MRI ................................................................................................................................................................................. 43

Patient preparation and education ......................................................................................... 43 Breast imaging ............................................................................................................................................................... 43 Pelvic/fetal ultrasound ................................................................................................................................................... 43

Studies that should be watched during elective period or during clinical rotations .................. 44 Breast imaging ............................................................................................................................................................... 44 Pelvic/fetal ultrasound ................................................................................................................................................... 44

2. Normal anatomy ................................................................................................. 44

Structures that should be identified on each modality ........................................................... 44 Breast imaging ............................................................................................................................................................... 44 Pelvic/fetal ultrasound ................................................................................................................................................... 44


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Common pathological conditions/findings that the student should recognize or at least see examples of: .......................................................................................................................... 44 Breast imaging ............................................................................................................................................................... 44 Pelvic/fetal ultrasound ................................................................................................................................................... 44


Diagnostic situations/conditions unlikely to benefit from imaging ......................................... 45


Identify clinical scenarios where image-guided procedures are beneficial ............................... 45 Breast ............................................................................................................................................................................. 45 Pelvic/fetal ultrasound ................................................................................................................................................... 45


Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging .................................................................................................................................. 45 Breast Imaging ............................................................................................................................................................... 46 Pelvic/fetal ultrasound ................................................................................................................................................... 46 Indications for pelvic MR in non-pregnant woman ....................................................................................................... 46 Indications for MRI in pregnancy ................................................................................................................................... 46

Incorporating imaging findings into patient management including effects of pre-test probabilities .......................................................................................................................... 47 Breast imaging ............................................................................................................................................................... 47 Pelvic and fetal ultrasound ............................................................................................................................................ 47

Neuroimaging ............................................................................................................... 48




Studies that should be watched during elective period or clinical rotations ............................ 48

2. Normal anatomy ................................................................................................. 48

Structures that should be identified on each modality ............................................................ 48


Common pathological conditions/findings that the student should recognize or at least see examples of: .......................................................................................................................... 49 Tumors ........................................................................................................................................................................... 49 Infection ......................................................................................................................................................................... 49 Trauma ........................................................................................................................................................................... 49 Vascular disease ............................................................................................................................................................. 49 Miscellaneous: ............................................................................................................................................................... 49



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5. Imaging algoritms (appropriateness criteria) ...................................................... 50

Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging .................................................................................................................................. 50

Incorporating imaging findings into patient Management including effects of pre-test probabilities .......................................................................................................................... 50

Nuclear Medicine .......................................................................................................... 51





2. Normal anatomy ................................................................................................. 51



Common pathological conditions/findings that the student should recognize or at least see examples of ........................................................................................................................... 51







Appropriate imaging algorithms for common diagnostic situations ......................................... 52 Indications for common nuclear medicine exams: (Tracers used for these exams) ...................................................... 52

Incorporating imaging findings into patient Management including the effects of pre-test probabilities .......................................................................................................................... 53

Pediatrics ...................................................................................................................... 54





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2. Normal anatomy ................................................................................................. 54

Structures that should be identified on each modality or at least seen during elective ............ 54 Abdomen: ...................................................................................................................................................................... 54 Skeletal plain films: ........................................................................................................................................................ 54 Brain ............................................................................................................................................................................... 55


Common pathological conditions/findings that the student should recognize or at least see examples of: .......................................................................................................................... 55 Infections: ...................................................................................................................................................................... 55 Tumors: .......................................................................................................................................................................... 55 Congenital abnormalities: .............................................................................................................................................. 55 Neonates: ....................................................................................................................................................................... 55






Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging .................................................................................................................................. 56 Contraindicated studies ................................................................................................................................................. 56


Curriculum Resources.................................................................................................... 57

1. Teaching Methods .............................................................................................. 57

Group based conferences ....................................................................................................... 57

Student presentations ............................................................................................................ 57

One-on-one based teaching/shadowing ................................................................................. 57

Informal Quizzes .................................................................................................................... 58

Formal Exams ........................................................................................................................ 58

Games ................................................................................................................................... 58

Self-learning exercises ............................................................................................................ 59

Hands-on-practical experiences .............................................................................................. 59

2. Websites ............................................................................................................. 59

Casefiles ................................................................................................................................ 59

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Teaching programs ................................................................................................................. 60

General information and Portals ............................................................................................ 61

3. CDROM based programs ..................................................................................... 62

4. Textbooks ........................................................................................................... 62

Comprehensive radiology textbooks for medical students: ..................................................... 62

Problem or case-based format: .............................................................................................. 63

Pattern recognition format: ................................................................................................... 63

Pocket format: ....................................................................................................................... 63

Diagnostic Shortlist : The “Must See” Images................................................................ 65

Example of Goals and Objectives for a Student Elective ................................................ 67

Introduction .................................................................................................................. 67

Reading room ............................................................................................................... 67 Goals of rotation ............................................................................................................................................................ 67 Specific recommendations ............................................................................................................................................. 67 Additional reading.......................................................................................................................................................... 68

CT/Body Imaging .......................................................................................................... 68 Goals of rotation ............................................................................................................................................................ 68 Specific recommendations ............................................................................................................................................. 68 Additional reading.......................................................................................................................................................... 69

Neuroimaging ............................................................................................................... 69 Goals of rotation ............................................................................................................................................................ 69 Specific recommendations ............................................................................................................................................. 69 Additional reading.......................................................................................................................................................... 70

Fluoroscopy .................................................................................................................. 70 Goals of rotation ............................................................................................................................................................ 70 Specific recommendations ............................................................................................................................................. 70 Additional reading.......................................................................................................................................................... 70

Mammography ............................................................................................................. 71 Goals of rotation ............................................................................................................................................................ 71 Specific recommendations ............................................................................................................................................. 71 Additional reading.......................................................................................................................................................... 72

Ultrasound .................................................................................................................... 72 Goals of rotation ............................................................................................................................................................ 72 Specific recommendations ............................................................................................................................................. 72 Additional reading.......................................................................................................................................................... 72

Interventional radiology ............................................................................................... 73 Goals of rotation ............................................................................................................................................................ 73 Specific recommendations ............................................................................................................................................. 73

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Additional reading.......................................................................................................................................................... 73

Nuclear Medicine .......................................................................................................... 74 Goals of rotation ............................................................................................................................................................ 74 Specific recommendations ............................................................................................................................................. 74 Additional reading.......................................................................................................................................................... 74

Self study time .............................................................................................................. 75 Goals of rotation ............................................................................................................................................................ 75 Suggestions for self study resources .............................................................................................................................. 75

Private practice day ...................................................................................................... 75 Goals of rotation ............................................................................................................................................................ 75 Specific recommendations ............................................................................................................................................. 76

Diagnosis Please links ................................................................................................... 76

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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 can be used as guidelines for those programs that wish to develop their own curriculum.

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

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Curricular Framework

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

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

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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

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

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 are all available at AMSER-ID as a shared resource.

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Goals and Objectives

Aim: To provide an example of goals and objectives that can be modified for specific programs. Outline: Modality-specific goals and objectives, specific recommendations for students while on clinical rotations

and suggestions for further study with hyperlinked web-resources. These guidelines come from Dartmouth-Hitchcock Medical Center.

AMSER Shared Resources

Are found at

http://www.dartmouth.edu/~amserimages/ Login: amserid

Password: roentgen

These include a 4000+ image dataset of commonly found conditions, lectures, curricula and other shared resources donated by AMSER members.

Radiology ExamWeb

Is found at:

http://radiology.examweb.com

National database of multiple choice questions for students on radiology rotations

Open for all AMSER members/clerkship and elective directors

Exams developed, shared and taken on-line

For more information on using this resource contact [email protected]

http://www.dartmouth.edu/~amserimages/

http://radiology.examweb.com/

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Core Topics

1. Physics concepts important to the clinician

What produces density differences on radiographs

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

Silhouette signs on CXR/KUB

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

2. 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

3. Contrast media Types of contrast media

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Intracavitary:

Bowel Rationale Types (barium, water soluble, gastrograffin) 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

4. Orientation to radiology department (specific to individual programs)

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

Getting wet readings

Office hours/on call

Accessing reports

Dictation system/written Preliminary versus final reports

Use of PACS system (specific to individual programs)

Accessing images Manipulating images Downloading images for presentations Importance of reading reports Confidentiality/legal issues

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5. Radiation safety and risks

Risks associated with radiation exposure

Hematological malignancies Solid organ malignancies Local skin effects Teratogenetic effects ALARA principle

CXR equivalents of common examinations (or use period natural exposure)

Lumbar spine films 20 KUB 75 VQ scan 80 Bone scan 180 Myocardial perfusion 250 Chest CT 400 (approx. 20 yrs of 2 view mammograms) Abdo/Pelvic CT 750

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

Age dependance of radiation sensitivity

Cancer incidence with age exposure Importance of reducing pediatric radiation exposure

6. 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 Tc

99m 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 1

st trimester, gadolinium occassionally used for strong indications (e.g

ovarian tumors)

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)

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Suspected PE – CXR then perfusion scan +/- ventilation scan if abnormal

Studies that should be performed if absolutely necessary with shielding if possible

KUB Limited IVP CT, but limited dose

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

7. Other „risks‟ of radiology

Contrast media

Complications Local pain and vomiting Extravasations with tissue necrosis Allergic reactions Incidence (minor 3+%, severe: 0.2% for high osmolar, <0.04% for low osmolar, fatal 1:170,000) 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

e.g. prednisone 50mg po 13 hours, 7 hours, and 1 hour prior to the exam +/- benadryl 50mg po one hour priory.

Pre and post hydration N-acetyl cysteine CO2 angiography

Risks of percutaneous biopsies and drainage procedures

Bleeding, infection, organ damage, pneumothorax

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Claustrophobia

MRI>CT>nucs or fluoro

Complications specific to fluoroscopy

Bowel perforation Barium impaction Barium mediastinitis and peritonitis Aspiration of contrast media (barium vs. ionic vs. non-ionic contrast media

Complications specific to nuclear medicine

Allergic reactions extremely rare except antibody studies Persantine/adenosine reactions

Complications specific to MRI

Ferromagnetic displacement (eye debris, aneurysm clips, objects) Electrical interference (pacemakers, defibrillators, neuro-stimulators) Artifacts from metallic prostheses and debris

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

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

8. Financial costs

Patient and society Comparative charges for common examinations at student‟s institution Example: (from DHMC)

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

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Colonoscopy 16

Bone scan 5

PET scan 16

VQ scan 6

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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

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: Uses

Pulmonary angiography: Uses

Nuclear medicine: (FDG lung cancer) – covered under nucs curriculum VQ scans- covered under nucs curriculum

Patient preparation and education

Fasting 6hr for PET FDG scan Need to hold breath for CT, respiratory gating MR

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

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

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Position of heart valves Mediastinum:

SVC Carotid and subclavian vessels 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.

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

NMSCR 11/19/2010 25

Appearance of great vessel ectasia Thoracic aortic aneurysm Ruptured aorta Aortic dissection 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

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

Emergency “don‟t miss” findings (CXR)

Tension pneumothorax Supine pneumothorax (deep sulcus sign)

NMSCR 11/19/2010 26

LUL collapse Pulmonary edema (interstitial and alveolar) Sub-diaphragmatic air Pneumomediastinum Signs of aortic dissection Aortic rupture (supine CXR, CT) Dobhoff in trachea/bronchus

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

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)

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)

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

NMSCR 11/19/2010 27

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 Management of the normal supine CXR in high risk trauma patient

NMSCR 11/19/2010 28

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.



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


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)

Studies that should be watched during elective period

UGI Barium enema CT scan RUQ ultrasound Pelvic ultrasound VCUG

2. Normal anatomy

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

NMSCR 11/19/2010 29

Spleen Pancreas Aorta IVC Kidneys Ureters Bladder Uterus Ovaries



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

Emergency “don‟t miss” findings

Free air – upright chest, supine, decubitus and upright KUB, CT SBO Cecal and sigmoid volvulus Free fluid on CT

NMSCR 11/19/2010 30

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)



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)

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

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

NMSCR 11/19/2010 31

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.



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


No driving after shoulder arthrogram Post-procedure pain management Importance of holding still during CT/MR

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


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:

NMSCR 11/19/2010 32

Diaphysis, metaphysis, epiphysis Common normal variants:

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


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 5

th 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

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Anterior shoulder dislocation and Hill Sachs fracture Phalangeal dislocations 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


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)


Ankle sprain


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


NMSCR 11/19/2010 34

Appropriate imaging management algorithms for common diagnostic situations including cost-effective imaging

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)

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)

NMSCR 11/19/2010 35

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.


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


Pre-procedure labs required (coags, platelets, renal function) Peri- and post-procedure pain management Risks and contraindications of sedative drugs

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

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)

NMSCR 11/19/2010 36

2. Normal anatomy


Refer to organ specific curriculae


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


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.



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)

NMSCR 11/19/2010 37

Paracentesis for ascites Ureteric obstruction (nephrostomy tube, internal/eternal drainage) Biliary obstruction

Angioplasty, direct intravascular thrombolysis and stent placements Peripheral ischemia 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


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)

NMSCR 11/19/2010 38

Management of dialysis access (central vs peripheral) Management of pancreatic head tumors (percutaneous vs endoscopic biopsies)

NMSCR 11/19/2010 39

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.



Plain films (see core curriculum), include use of portable studies, trauma series CT: “trauma study” Ultrasound for intraperitoneal fluid


Short CT preps for trauma Education about lack of need for imaging in certain conditions

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


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


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)

NMSCR 11/19/2010 40

Common appendicular fractures/dislocations including:

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 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 5

th 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)

NMSCR 11/19/2010 41

Ruptured abdominal aortic aneurysm (CT, Ultrasound) Renal calculi (KUB, CT) Intraperitoneal free air Small bowel obstruction 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


Misplaced naso/oral gastric tubes Correct position of chest tubes Correct position of endotracheal tubes Correct position of central lines Iatrogenic pneumothorax and pneumomediastinum


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


Use of CXR rather than rib films in suspected rib fractures

NMSCR 11/19/2010 42

Coccygeal fractures (no imaging) Ankle injuries that do not fulfill Ottawa ankle criteria Ambulating patients for r/o tibia/fibula fxs



Ultrasound guided thoracocentesis and paracentesis Pigtail catheter placement for pneumothorax

5. Imaging algorithms (appropriateness criteria) and cost effective imaging

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 HCG 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)


Management of suspected ectopic pregnancy when no gestational sac seen Management of the high suspicion but imaging negative ?PE case

NMSCR 11/19/2010 43

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.



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)


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

NMSCR 11/19/2010 44

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

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



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:

NMSCR 11/19/2010 45

Neuro (hydrocephalus, Chiari malforms, neural tube defects, anencephaly, etc) 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.


Recognition not required at general medical student level

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 HCG<1000 IU)



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



NMSCR 11/19/2010 46

Breast Imaging Currently recommended screening protocols (ACR) Effect of screening mammography on breast cancer mortality rates Mammography screening in 40-50 age group controversies 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

NMSCR 11/19/2010 47

Complex body wall anomalies Concurrent maternal abdo-pelvic disease


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 HCG 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

NMSCR 11/19/2010 48

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.



NeuroCT and CT of the neck, sinuses and ear NeuroMR Cerebral angiography Spinal imaging-CT Spinal imaging-MR Myelography CTA/MRA


Importance of holding still for long periods for MRI NPO for several hours before IV contrast External halo devices for stereotactic procedures

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

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

NMSCR 11/19/2010 49



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


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


Skull films-NOT indicated in most cases of head trauma Timing for appearance of stroke findings

NMSCR 11/19/2010 50

CT for migrainous/recurrent headache



Treatment of berry aneurysms Biopsy of tumors Treatment of congenital vascular anomalies

5. Imaging algoritms (appropriateness criteria)


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

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

NMSCR 11/19/2010 51

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.



Outline of gamma camera operation Concept of radiopharmaceuticals, in general 99m

Tc as most commonly used isotope Concept of

18F-FDG PET scanning and PET-CT

Concept of physiological versus anatomical imaging


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


Bone scan or other routine planar study SPECT scan of some type Cardiac stress test and perfusion scan

2. Normal anatomy 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


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)

NMSCR 11/19/2010 52

Obvious myocardial infarct/ischemia (myocardial perfusion study) Acute cholecystitis (hepatobiliary scan) Toxic nodule (thyroid scan) Graves' disease UPJ obstruction (MAG3/DPTA scan) Metastastic tumor (PET FDG scan)


Bile leaks s/p cholecystectomy Ureteral obstruction


Emergency interpretation of nuclear medicine studies not expected by students or non-radiology interns/residents


Delayed imaging in GI bleeding scans Bone scans in myeloma



Shunt patency studies


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 (

99mTc pertechnetate,

123I NaI,

131I NaI)

Thyrotoxicosis Thyroid nodules Ventilation perfusion [VQ] scan (

99mTc macro-aggregated albumin,

133Xe ,

99mTc 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

NMSCR 11/19/2010 53

MUGA (99m

Tc labeled RBC)

Ejection fraction and wall motion prior to chemotherapy Evaluation of ischemic heart diease (+/- stress)

Hepatobiliary scan (

99mTc DISIDA/mebrofenin)

Suspected acute cholecystitis Suspected chronic cholecystitis/biliary dyskinesis (CCK) Renal scan (

99mTcDPTA or MAG3 or DMSA)

Obstruction Renovascular hypertension Renal infarction Gastrointestinal bleeding scan (

99mTc labeled red blood cells)

GI bleed with negative endoscopy Gastric emptying study (

99mTc sulfur colloid labeled egg sandwich)

Suspected gastroparesis or gastric outlet obstruction White blood cell [WBC] scan (

99mTc HMPAO or

111In oxine labeled white blood cells)

Osteomyelitis PET scan (

18F 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)

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

NMSCR 11/19/2010 54

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.



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


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


VCUG Barium swallow/UGI Abdominal ultrasound Chest radiograph KUB Cranial ultrasound

2. Normal anatomy

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

NMSCR 11/19/2010 55

Brain Normal neonatal brain appearance (US, CT)



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


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


Chronic abdominal pain Recurrent, uncomplicated asthma



Biopsy Abscess drainage PICC line placement Prenatal therapy

NMSCR 11/19/2010 56

Sclerotherapy (lymphatic malformations)



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


Management of borderline pyloric measurements in projectile vomiting Management of negative plain films in high suspicion bony injuries (e.g. distal humerus)

NMSCR 11/19/2010 57

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

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

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

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

NMSCR 11/19/2010 58

“Sub-intern” experience – assigned cases for interpretation

Individual OSCE with structured questions and immediate feedback

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

Formal Exams

http://radiology.examweb.com

o National database of multiple choice questions for students on radiology rotations.

o Exams developed, shared and taken

o For more information contact [email protected]

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

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).

http://radiology.examweb.com/

NMSCR 11/19/2010 59

Use of audience response pads

Use of team/individual response buzzers

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

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

Casefiles

AMSER Shared Resources are found at http://www.dartmouth.edu/~amserimages/

Login: amserid Password: roentgen

These include a 4000+ image dataset of commonly found conditions, lectures, curricula and other shared resources donated by AMSER members

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.

Washington University, Musculoskeletal Teaching file (http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/teaching-files) Excellent MS teaching file as well as other info

http://www.dartmouth.edu/~amserimages/

http://www.uhrad.com/pedsarc.htm

http://www.pediatricradiology.com/

http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/teaching-files

NMSCR 11/19/2010 60

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

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.

Mallinkrodt teaching files (http://gamma.wustl.edu/home.html)

Excellent nuclear medicine teaching cases

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. Nice chest CT anatomy section.

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 Skeletal Anatomy (http://uwmsk.org/RadAnatomy.html) Review of basic skeletal anatomy on plain films. This site also has more complex MRI-based MS anatomy tutorials

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

http://www.evaluation.idr.med.uni-erlangen.de/Ecomparetitlepage.htm

http://www.uhrad.com/

http://www.radiology.co.uk/srs-x/cases.htm

http://chorus.rad.mcw.edu/

http://brighamrad.harvard.edu/education.html

http://gamma.wustl.edu/home.html


http://www.chestx-ray.com/

http://www.med-ed.virginia.edu/courses/rad/radmain.jpg

http://www.med.umich.edu/lrc/breastcancerdetective

http://uwmsk.org/RadAnatomy.html

http://www.lumen.luc.edu/lumen/meded/grossanatomy/x_sec/mainx_sec.htm

http://brighamrad.harvard.edu/education.html

http://sprojects.mmi.mcgill.ca/radiology/

NMSCR 11/19/2010 61

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

Yale Cardiothoracic Imaging (http://www.med.yale.edu/intmed/cardio/imaging/).

Comprehensive audio and visual modules covering plain film, ct, mri and angiography of the

cardiothoracic system. Normal and abnormal. Primarily for residents, but also of interest to

students.

Beth Israel (Gillian Lieberman) web-tutorials

(http://www.bidmc.org/MedicalEducation/Departments/Radiology/MedicalStudents.aspx) .

This is an extensive series of sites, containing modules for students as well as primary care

practitioners. It includes flash and ppt modules, some with voice. Excellent and

comprehensive site, esp for chest and abdomen. Some files very large.

Dartmouth anatomy (Nancy McNulty) (http://www.dartmouth.edu/~anatomy)

Basic anatomy and radiological anatomy modules, most suitable for first year students or

refresher for clinical years.

CT/MRI/cadaver anatomy from Univ Aukland

(http://www.fmhs.auckland.ac.nz/sms/anatomy/atlas/intro.aspx)

Sectional anatomy with CT and MRI correlation of entire body

Anatomy modules from West Virginia University (http://anatomy.hsc.wvu.edu/eStudyGuide/SecondLevel/Radiologic/P2index.swf) Various radiological anatomy modules, both plain film and cross sectional

SUNY Downstate brain MRI anatomy (http://ect.downstate.edu/courseware/neuro_atlas/mri_horizontal.html)

OB Ultrasound.net (Joseph Woo) (http://www.ob-ultrasound.net/). Nice introductory site for students interested in learning the rudiments of obstetrical ultrasound.

Beth Israel nuclear medicine tutorial (http://mycourses.med.harvard.edu/vp_view.asp?frame=Y&case_id=%7BA05B20FA-F648-468F-BB4C-F6FE9ED09438%7D) Course designed for primary care physicians covering the indications and descriptions of the common nuclear medicine studies. Nice review for students.

General information and Portals

AMSER (http://www.aur.org/Affiliated_Societies/amser/index.cfm) 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

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....

http://www.learningradiology.com/

http://www.med.yale.edu/intmed/cardio/imaging/


http://www.bidmc.org/MedicalEducation/Departments/Radiology/MedicalStudents.aspx


http://www.dartmouth.edu/~anatomy


http://www.fmhs.auckland.ac.nz/sms/anatomy/atlas/abdomen/abdomen_visible_1.aspx

http://www.fmhs.auckland.ac.nz/sms/anatomy/atlas/intro.aspx

http://anatomy.hsc.wvu.edu/eStudyGuide/SecondLevel/Radiologic/P2index.swf



http://ect.downstate.edu/courseware/neuro_atlas/mri_horizontal.html


http://www.ob-ultrasound.net/


http://mycourses.med.harvard.edu/vp_view.asp?frame=Y&case_id=%7BA05B20FA-F648-468F-BB4C-F6FE9ED09438%7D



http://www.aur.org/Affiliated_Societies/amser/index.cfm

http://www.auntminnie.com/

NMSCR 11/19/2010 62

Association of Program Directors in Radiology (http://www.apdr.org/) Includes information for medical students, teaching resources and program information

RSNA (http://www.rsna.org/residency.cfm) Links for medical students interested in a career in Radiology.

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

ACR appropriateness criteria (ttp://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx) A must for every medical student to know about. Useful resource for image algorithm sessions.

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)

4. Textbooks

Comprehensive radiology textbooks for medical students:

Essential Radiology: Clinical Presentation, Pathophysiology, Imaging 2nd Edition by Richard Gunderman Publisher: Thieme Medical Publishers, Incorporated Pub. Date: January 2006 ISBN-13: 9781588900821 Squire's Fundamentals of Radiology: Sixth Edition by Robert A. Novelline Publisher: Harvard University Press Pub. Date: February 2004 ISBN-13: 9780674012790 Medical Imaging by Peter Scally Publisher: Oxford University Press, USA (February 17, 2000) Language: English

http://www.apdr.org/edu_portal.htm

http://www.rsna.org/residency.cfm

http://www.radiologyeducation.com/

http://www.medicalstudent.com/

http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Robert+A%2E+Novelline

http://www.amazon.com/exec/obidos/search-handle-url/ref=ntt_athr_dp_sr_1?%5Fencoding=UTF8&search-type=ss&index=books&field-author=Peter%20Scally

NMSCR 11/19/2010 63

ISBN-10: 0192630563 ISBN-13: 978-0192630568 Blueprints Radiology (2nd Edition) by Alina Uzelac, Ryan W. Davis, Ryan Davis Publisher: Lippincott Williams & Wilkins Pub. Date: October 2005 ISBN-13: 9781405104609 Essentials of Radiology by Fred A. Mettler Jr. Publisher: Elsevier Science Pub. Date: September 2004 ISBN-13: 9780721605272 Clinical Radiology: The Essentials 3rd edition by Daffner, Richard H Daffner, Richard H Publisher: Lippincott Williams & Wilkins Pub. Date: February 2007 ISBN-13: 9780781799683 The Hands-On Guide to Imaging by David C. Howlett, Brian Ayers Publisher: Wiley, John & Sons, Incorporated Pub. Date: September 2004 ISBN-13: 9781405115513 Imaging for Students by David Lisle Publisher: Hodder Arnold Pub. Date: March 2007 ISBN-13: 9780340925911

Problem or case-based format:

Case Studies in Medical Imaging: Radiology for Students and Trainees by Anil T. Ahuja (Editor), Gregory E. Antonio (Editor), K. T. Wong (Editor) Publisher: Cambridge University Press Pub. Date: August 2006 ISBN-13: 9780521682947

Pattern recognition format:

Learning Radiology: Recognizing the Basics: by William Herring Publisher: Elsevier Science Pub. Date: May 2007 ISBN-13: 9780323043175

Pocket format:

The Radiology Handbook: A Pocket Guide to Medical Imaging by J. S. Benseler Publisher: Ohio Univ Pr Pub. Date: September 2006 ISBN-13: 9780821417089

Radiology Recall 2nd Edition by Spencer B. Gay, Richard J. Woodcock Jr., Richard J. Woodcock (Editor) Publisher: Lippincott Williams & Wilkins Pub. Date: November 2007

http://xisbn.worldcat.org/liblook/resolve.htm?res_id=http://libcat.dartmouth.edu&rft.isbn=0192630563&url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:book

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Alina+Uzelac

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Ryan+W%2E+Davis

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Ryan+Davis

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Fred+A%2E+Mettler+Jr%2E

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Daffner%2C+Richard+H+Daffner%2C+Richard+H

http://search.barnesandnoble.com/booksearch/results.asp?ATH=David+C%2E+Howlett

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Brian+Ayers

http://search.barnesandnoble.com/booksearch/results.asp?ATH=David+Lisle

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Anil+T%2E+Ahuja

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Gregory+E%2E+Antonio

http://search.barnesandnoble.com/booksearch/results.asp?ATH=K%2E+T%2E+Wong

http://search.barnesandnoble.com/booksearch/results.asp?ATH=William+Herring

http://search.barnesandnoble.com/booksearch/results.asp?ATH=J%2E+S%2E+Benseler

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Spencer+B%2E+Gay

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Richard+J%2E+Woodcock+Jr%2E

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Richard+J%2E+Woodcock

NMSCR 11/19/2010 64

ISBN-13: 9780781765596

NMSCR 11/19/2010 65

Diagnostic Shortlist : The “Must See” Images Images all students should see

This is a limited list of diagnoses and their respective imaging modalities that all students should be shown and be able to recognize classic examples of, regardless of their planned speciality. Images that can be used for teaching this list are available at AMSER-ID (see websites above).

Condition Details Modalities

Pneumothorax Upright, supine, signs of tension,

adult and child CXR, CT

Pneumonia Lobar, sublobar, viral, spine sign CXT, 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 Knees, ankles, wrist, elbow Plain films

NMSCR 11/19/2010 66

Elbow joint effusion Radial head fracture, distal

humneral fracture Plain films, child and adult

Shoulder dislocation Anterior and posterior Plain films

Buckle fractures Radius, child Plain films

Scaphoid fracture Plain films

Proximal femoral fracture Obvious and more subtle Plain films

NMSCR 11/19/2010 67

Example of Goals and Objectives for a Student Elective

This is an example of modality specific goals and objectives for 4

th year medical students on a 4-week rotation

in radiology (from Dartmouth-Hitchcock Medical Center). It includes web resource links for the students. (current version available at http://docs.google.com/View?id=dc544pq3_2ds3ks2dg )

Goals and Objectives for Medical Students on Radiology Elective at DHMC

Introduction This document is intended to focus student educational efforts on the elective and also to provide guidance to staff within specific areas. These goals and objectives include material covered during letures and workshops and self study time as well as clinical rotations.

Reading room

Goals of rotation

Learn normal CXR anatomy and become familiar with the range of normal appearances through seeing multiple examples of normal films

Gain a familiarity with the interpretation of portable CXRs

Identify the different CXR views and when they are helpful, as well as the limitations of each (PA, AP, lateral, supine, upright, decubitus, expiratory, lordotic)

Learn to recognize common conditions on CXRs: Pneumonia, pneumothorax, pleural effusions, pulmonary edema, ARDS atelectasis, cardiomegaly, pulmonary masses, granulomas, hilar enlargement, COPD/emphysema, aortic rupture

Learn to identify correct and incorrect tube placements: Central lines, ETT, PICC, NG, Dobhoff

Learn the common indications for performing CXRs and when additional imaging with CT, MRI or nuclear medicine studies may be helpful

Be able to recognize some of the common plain film MSK abnormalities: Hip fracture, ankle fractures, scaphoid fracture, wrist fractures inc. buckle fractures, osteoarthritis, rheumatoid arthritis, knee and elbow effusions, spinal compression fracture, shoulder dislocation

Understanding how we describe fractures

Understand the importance of obtaining the appropriate views (scaphoid, radial head, shoulder internal and external rotation)

Know some of the indications for and benefits of obtaining further imaging with MRI, CT or arthrography

Specific recommendations

Read Felson CXR workbook (provided)

Review CXR anatomy

http://docs.google.com/View?id=dc544pq3_2ds3ks2dg

http://docs.google.com/View?id=dc544pq3_2ds3ks2dg

http://eradiology.bidmc.harvard.edu/Classics/list.aspx?section=Chest

http://eradiology.bidmc.harvard.edu/Classics/list.aspx?section=Support+Lines

http://eradiology.bidmc.harvard.edu/Classics/list.aspx?section=Musculoskeletal

http://www.learningradiology.com/medstudents/recognizingseries/recogfxsflashpage.htm

http://www.med-ed.virginia.edu/courses/rad/cxr/index.html

NMSCR 11/19/2010 68

If in the RR in the morning, you should ensure that you sit in on the on-call resident readout

Aim to spend your time in the reading room predominately split between the chest and float staff

Those with an interest in pediatric imaging should spend time with Drs. Vaccaro and Sargent on M, T, Th pms

Those with an interest in MSK imaging, should spend some time with Drs. Goodwin and Cheung in the MSK room - note, MSK plain films are also read by float radiologists

Pre-read films (6-8 at a time) then review with radiologist who will dictate

Additional reading

Learningradiology.com (various modules)

How to see abnormalities on CXRs from www.cxr.com

University Virginia CXR module

University Virginia ICU chest film module

CT/Body Imaging

Goals of rotation

Develop a method, or approach to evaluate CT scans of the chest, abdomen and pelvis

Review normal CT anatomy of the chest, abdomen and pelvis

Learn about the different scanning techniques and understand why they are performed. Be familiar with some general protocol categories: CT angiography, multiphase imaging protocols, CT enterography

Learn about contrast allergies, the contraindications to iv contrast, and prevention of contrast reactions with steroids

See CTs and CT guided procedures performed so that you can explain them to patients

Learn the radiation risks of CT, understand how those risks differ in different patient populations, and understand methods which can be used to reduce the risk: Dose reduction techniques, Limiting the region scanned, limiting repeat CTs

Learn the CT findings of commonly encountered acute conditions: Diverticulitis, colitis, appendicitis, pancreatitis, renal stone disease,pulmonary embolism, aortic dissection, pneumoperitoneum,hemoperitoneum, aortic rupture and dissection,

Learn the CT findings of commonly encountered chronic conditions: Solid organ tumors, metastases, ascites, lymphoma, aortic aneurysms


Read out the on-call CTs with on-call resident (if you are in the reading room this may occur during that rotation)

If a workstation is available, pre-read appropriate CT scans (one at a time) before reviewing with staff radiologist

http://www.learningradiology.com/medstudents/medstudtoc.htm

http://www.chestx-ray.com/Lectures/HowToSee/NavigationHowToSee.html

http://www.med-ed.virginia.edu/courses/rad/cxr/index.html

http://www.med-ed.virginia.edu/courses/rad/chest/index.html

NMSCR 11/19/2010 69

Towards the end of the rotation, sit down with the resident who is doing the protocols and learn about how we choose which protocol to use.

Spend time in the CT core area observing the technologists performing at least 2 scans; one of these should include an iv contrast injection.

Observe or participate in a CT guided biopsy. Review the patient history, learn the indication for the procedure, understand the technique used, follow up on the pathology results.

Observe or participate in a CT guided drainage. Review the patient history, learn the indication for the procedure, understand the technique used. If applicable, follow up on the microbiology results.

Additional reading

CT/MRI/cadaver anatomy from Univ Aukland

CT abdomen and pelvis from WVU

CT chest anatomy from chestxray.com

Neuroimaging

Goals of rotation

Understand the strengths, weaknesses and limitations of CT vs. MRI in the evaluation of patient‟s with central neurologic symptoms and diseases

Understand the strengths, weaknesses and indications of spine CT, MRI, and myelography in the evaluation of the spine and spinal cord

Understand the indications for conventional carotid and cerebral angiography, its risks and benefits in comparison with CTA and MRA

Understand the role of imaging (including MRI vs. CT) in the evaluation of common clinical complaints, including stroke, headache, trauma, mass lesions, back pain, radiculopathy and demyelinating disease

See how different MR sequences are used to identify different pathophysiological processes.

Understand the usual appearances of gray matter, white matter, fluid, edema, masses, blood, and fat on common MR sequences (T1, T2, FLAIR, STIR )

Know some of the uses of contrast in MRI and CT

Review basic neuroanatomy on head CT and MRI

Develop a basic but comprehensive standard method to evaluate routine non-contrast head CTs

Get an overview of common procedures done in neuroradiology, including the use of nerve root blocks for management of back pain and vertebroplasty for compression fractures

Be able to recognize the appearance of common pathological processes such as stroke, edema, herniation, subdural, epidural and subarachnoid hemorrhage on CT


Be involved in the morning readout of the call resident (usually around 8am)

Accompany the neuroradiology fellow/resident during the workup and performance of nerve root blocks and vertebroplasties

http://www.fmhs.auckland.ac.nz/sms/anatomy/atlas/abdomen/abdomen_visible_1.aspx


http://www.chestx-ray.com/Anatomy/CrossSections/CrossSection.html

NMSCR 11/19/2010 70

Become an active participant in the daily MR and CT reading including pre-reading studies when a workstation is available

Additional reading University Virginia Intro to Head CT module

University Virginia Evaluation of the Cervical Spine

SUNY Downstate brain MRI anatomy

Fluoroscopy

Goals of rotation

Understand how fluoroscopy is used to image cavities and lumen

Learn the difference between the different fluoroscopic tests and what structures they image: Modified swallow, single and double contrast swallow, UGI, small bowel follow through, single, air and double contrast enemas, IVP, VCUG

Learn the common indications for fluoroscopic tests

See studies performed so that you can explain them to patients: Ba swallow, UGI, enema, VCUG, arthrogram, IVP

Understand the advantages and limitations of fluoroscopy

Understand some of the risks of fluoroscopy - radiation, contrast extravasation/aspiration, perforation

Understand the differences between the various contrast medias used in fluoroscopy

Learn normal KUB anatomy and become more comfortable with the range of normal appearances

Become familiar with interpretation of common conditions on plain abdominal radiographs: Obstruction, free air, illeus, abnormal calcifications (vascular, gallbladder, renal, bladder), large masses


Pre-read KUB studies and then review with radiologist

Follow at least one patient through a study with the technologist,

preferably one of the more complex studies such as an enema. You should have worked up this patient beforehand on CIS.

Be present at the 8am case discussion each morning. Watch the studies being performed with the resident/attending (in room with lead unless pregnant) and the interpretation afterwards Try to see as wide a variety of studies being performed as possible including pediatric studies

Additional reading

University Virginia GI site (this may be more detailed than you need but good sections)

Learningradiology.com plain abdominal film intrepretation

Learningradiology.com (various student modules)

http://www.med-ed.virginia.edu/courses/rad/headct/index.html

http://www.med-ed.virginia.edu/courses/rad/cspine/index.html


http://www.learningradiology.com/lectures/gilectures/Plain%20Films%20of%20the%20Abdomen/player.html

http://www.med-ed.virginia.edu/courses/rad/gi/index.html

http://www.learningradiology.com/lectures/gilectures/Plain%20Films%20of%20the%20Abdomen/player.html


NMSCR 11/19/2010 71

Mammography Goals of rotation

See how mammograms and breast ultrasound are performed

Be able to briefly describe mammographic procedures to patients

See how we use different mammographic views and ultrasound for problem solving in diagnostic mammography

Understand the differences between screening and diagnostic mammography

Know the effect of screening mammography on survival rates Know the current recommendations for screening mammography and MRI

Understand the management of screening 'call back' patients

Understand the meaning of BIRADS 0-6 categories

Know the indications for referral for diagnostic mammography and how to indicate the abnormality appropriately.

Know the current indications for breast MRI.

Understand some of the limitations of breast imaging techniques including the effect of breast density.

See how ultrasound is used in the diagnostic setting and some of its limitations

Know what the options are for image guided procedures in the breast.

Understand how clinical examination and imaging are inter-related and how they affect management especially of palpable breast masses.

Understand what a radiologist is looking for on a mammogram and what those terms mean:

o Calcifications, Asymmetric densities, Architectural distortion, Masses.

See some examples of benign and malignant processes in the breast on mammography and ultrasound


Spend a minimum of one diagnostic session in mammography

See at least one full mammographic series (CC, MLO) being obtained by a technologist

Follow at least one patient through her diagnostic evaluation including additional mammo views and ultrasound, watching the tech performing the views as well the radiologist interpreting them.

Perform a clinical breast examination on consenting women with palpable masses prior to the ultrasound

Look up the BIRADS categories

Go through CORE Women's Imaging Case 2 again

Review Dr. Poplacks lecture and/or this lecture from U.Washington on screening or this one on diagnostic mammography/breast MRI

For students spending > 1 session in mammography should also aim to:

o See image guided breast procedures performed, assist in basic patient care procedures where possible

http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp

http://www.yalemedicalgroup.org/news/dxrad/ymg_breastimaging.html

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/BIRADSAtlas/BIRADSFAQs.aspx

http://instruct.de/

http://www.rad.washington.edu/academics/academic-sections/mbi/education/medical-student-resources/clerkship-lectures-1/2006%20breast%20med%20clerkship%20lecture%20I%20screening.ppt/view

http://www.rad.washington.edu/academics/academic-sections/mbi/education/medical-student-resources/clerkship-lectures-1/breast%20med%20clerkship%20lecture%202%20diagnostic.ppt/view

NMSCR 11/19/2010 72

o See some examples of breast MR studies

Additional reading

ACS 2003 review and guidlelines for screening mammography

Breast Cancer Detective

Beth Israel (Lieberman) breast imaging module

Ultrasound

Goals of rotation

Gain hands-on practice in using ultrasound imaging:

Be able to find and recognize major intra-abdominal organs

Gain basic familiarity with how moving the transducer changes the imaging plane

See how altering scanning parameters such as gain, depth and focal zone affect our images

See how different transducers are used for different purposes

Learn the basic ultrasound imaging characteristics of tissues –

o simple fluid, complex fluid, soft tissue, bone, air, fat

See how the different types of Doppler ultrasound (m mode, pulsed, color and power) image motion

Learn the appropriate indications for the common ultrasound examinations

See some of the limitations of ultrasound –

o obesity, bowel gas etc

Learn classic appearance of common conditions:

o RUQ: gallstones, acute cholecystitis, biliary obstruction

o Abdominal aortic aneurysm

o Renal: renal stones, hydronephosis

o Pelvic: Fibroids, endometrial thickening, ovarian cysts, early pregnancy, normal 2nd trimester pregnancy

o Other: pleural fluid and ascites


Students should spend at least 50% of time with technologists watching scans

Scan patients themselves (not transvaginally), with patient permission after tech leaves room.

Remainder of time with attending/residents in reading room, helping with clinical workflow where possible.

After they see an abnormal study: look up brief background on condition/additional images (e.g. http://www.mypacs.net (search under ultrasound), www.ultrasoundcases.info or the Brigham teaching database.

Additional reading

http://caonline.amcancersoc.org/cgi/content/full/53/3/141

http://www.med.umich.edu/lrc/breastcancerdetective

http://eradiology.bidmc.harvard.edu/primarycare/breast.html

http://www.mypacs.net/

http://www.ultrasoundcases.info/



http://brighamrad.harvard.edu/education/online/tcd/bwh-query-modality.html



NMSCR 11/19/2010 73

University of Virginia Emergency Ultrasound

Introduction to obstetrical ultrasound

Interventional radiology

Goals of rotation

Learn how different imaging modalities are used to guide procedures and begin to understand when each is used: ultrasonography, fluoroscopy, CT, MRI

Be familiar with the indications and techniques of the following common IR procedures:

o central vascular access, fluid aspiration and drain placement, angiography, percutaneous nephrostomy, percutaneous transhepatic cholangiography, gastrostomy tube placement, percutaneous angioplasty and stent placement

Be able to describe to a patient the following procedures (observe any of these which occur the day you are on angio):

o Vascular access, angiography, fluid aspiration and drainage, tube placement in stomach (gastrostomy), kidney (nephrostomy)

Learn how we work up requests for IR procedures and the factors that go into determining if a procedure is necessary and indicated, safe, and able to be performed.


Introduce yourself to the staff of the day

Attend the morning conference to discuss the days cases. This begins at 7:15 am in the small reading room near angio; anyone in the angio suite can direct you

If you are spending more than one day in angio, in the afternoon before an IR day:

o Pick one case that you would like to be involved with from the board (check with the resident, fellow or NP/PA on the service) and participate in/do the patient work-up. Review the relevant patient history, allergies, medications, PMH, Labs and pertinent imaging studies. Understand the indications for the requested procedure and how it is performed. Write the pre-procedure note and have an attending review it and sign it

Put your initials on the angio board next to the cases you wish to participate in

Observe and/or participate in several additional IR cases from start to finish: Review the patient history, labs and relevant imaging, learn the indication for the procedure, learn the pre-procedure work up and patient preparation.

Follow the technologist and nurses as they set up the room, bring the patient in, position them and prep and drape the field. Understand the techniques used to perform the procedure.

Additional reading

Vascular anatomy- see "vasculature" section in each learning module

DHMC angio survival manual

http://www.med-ed.virginia.edu/courses/rad/edus/


http://docs.google.com/View?id=dhmdczz8_4c2z5smj2




NMSCR 11/19/2010 74

Nuclear Medicine

Goals of rotation

Understand the concept of physiological imaging

Radioisotopes vs. radiotracers

Learn some of the common indications for nuclear medicine studies

See examples of common examinations:

o PET-CT scans

o Bone scans

o Renal scans

o Hepatobiliary studies

o Cardiac perfusion scans

o VQ scan

o Thyroid scan

Know the appearance of common conditions on these studies

o PET-CT scans: lung cancer, metastatic disease

o Bone scans: metastases, trauma, degenerative changes

o Renal scans: obstruction

o Hepatobiliary studies: acute cholecystitis, CBD obstruction

o Cardiac perfusion scans (ischemia, infarction)

o VQ scan: pulmonary emboli

o Thyroid scan: Grave disease, hot and cold nodules

Understand some of the limitations of nuclear medicine examinations

Understand the difference between SPECT vs. PET

Know some of the important patient preparations for nuclear medicine studies (PET studies, thyroid, cardiac etc)

Know how common studies are performed to explain them to patients

Know some of the therapeutic uses of nuclear medicine (I-131 therapy)


Minimum 1/2 day in nuclear medicine

Spend 30+ minutes watching techs performing exams in department

The remainder of the time alternating between the attending reading PET-CT and conventional nuclear medicine studies

Many PET-CT scans are shown in CTOP conference Tues 8 am.

Additional reading

http://gamma.wustl.edu/clinical/preparation.html

NMSCR 11/19/2010 75

University Virginia Intro to PET-CT module

Intro to nuclear medicine ppt

Harvard teaching files

Mallinkrodt teaching files

Beth Israel nuclear medicine tutorial

Self study time

Goals of rotation

A variable amount of self study time is provided in the schedule depending on student learning style and requests, as well as the amount of time taken for interviews or other days out of the schedule. A maximum of 3 days is allowed, but time away is taken from this.

It is expected that this time ibe used to utilize text, web and CD/ROM learning resources and prepare for workshops and presentations.

Note: the self study room is NOT available M, Tu, W mornings

Suggestions for self study resources

CORE cases

Provided text books

CDROMS available through the student co'ordinator

Student teaching file in student room

Disc with Powerpoint presentations of lecture series

www.learningradiology.com (note, use the ppt links, some of the flash links go to adverts for his book)

University Virginia radiology tutorials

BrighamRad teaching cases

Beth Israel (Lieberman) web-tutorials (see list at bottom page)

Harvard guide to imaging in pregnant patients

Dartmouth Anatomy web-course

Yale cardiothoracic imaging module

ACR appropriateness criteria

AMSER National Curriculum in Radiology for Medical Students

Private practice day

Goals of rotation

Generally intended for students considering radiology as a career

http://www.med-ed.virginia.edu/courses/rad/PETCT/index.html

http://www.slideworld.org/viewslides.aspx/Nuclear-Medicine-ppt-22761

http://www.jpnm.org/elr.html




http://www.med-ed.virginia.edu/courses/rad/

http://brighamrad.harvard.edu/education/online/tcd/tcd.html


http://brighamrad.harvard.edu/education/fetaldose/index.html



http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx

http://docs.google.com/View?docid=dc544pq3_3gvq2w8rd

NMSCR 11/19/2010 76

See how a general private practice radiologist functions in a community hospital

One-on-one teaching with the radiologist


Most students go to Speare Hospital Plymouth (staffed by DHMC rads), but I have contacts with radiologists at St.Johnsbury also.

Shadowing with radiologist for a day, aid radiologist where possible

Diagnosis Please links

Diagnosis Please 1

Diagnosis Please 2

Diagnosis Please 3

http://docs.google.com/Presentation?id=dc544pq3_7hk3kgwch

http://docs.google.com/Presentation?id=dc544pq3_19ct462pfn

http://docs.google.com/Presentation?id=dhmdczz8_5fzmks3dx

Documents

Student Curriculum