#Fat? So what?

I read a lot of #CT scans. People come in different shapes and sizes.

Many requests say "abdominal pain" and more than half of my reports say normal or close to it.

Two patients, similar age with no acute findings to explain their pain.

What do the blue arrows represent?

Should my report still say normal?

Should my report include: Correlate with risk factors for metabolic syndrome?

Here's what the Mayo Clinic thinks of metabolic syndrome.

As of right now, I do not include this on my report - should I?

Will it make a difference when you meet with the patient with the results of the scan?

Blue arrows are subcutaneous fat, btw.

____________________________

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

#Poop and #belly #pain!

Too much stool? #orderwhat  @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Many radiologist would not specifically comment on stool burden.  I have made it part of my practice to include "Dense stool and air filled colon, correlate with signs and symptoms of constipation" when I see a radiograph like this.

If you get a normal report and you see the colon looking like this, consider constipation.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

Image credit:

http://pediatriceducation.files.wordpress.com/2009/01/122704constipationaxr.jpg?w=367&h=474

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Dysphagia?

Where does it get stuck?  #oropharynx #retrosternal #orderwhat  @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Known cause, Oropharynx => Modified barium swallow

Un-known cause, Oropharynx => pharyngeal dynamic radiographic exam

Retro-sternal => Bi-phasic esophagram and probably endoscopy 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Acute Pelvic Pain?

Acute Pelvic Pain? - #orderwhat #pain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Pregnant and gyn etiology suspected?  => US pelvis 

NOT Pregnant and gyn etiology suspected? US pelvis 

Pregnant and NON-gyn etiology suspected? US abdomen and possibly pelvis 

NOT Pregnant and NON-gyn etiology suspected? => CT abdomen and pelvis 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Vomiting infant - imaging needed? Bilious? X-ray or Ultrasound?

Vomiting In Infants Up To 3 Months Of Age?

Bilious vomiting in neonate up to 1 week old = abdomen radiograph and possibly upper GI or contrast enema

Bilious vomiting in infant 1 week to 3 months old = upper GI

Intermittent non-bilious vomiting since birth = possibly upper GI

New onset  projectile non-bilious vomiting = abdominal ultrasound 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Osteomyelitis in diabetic foot?

Imaging of suspected osteomyelitis in diabetic foot?

Summary

Soft tissue swelling with or without neuropathic arthropathy or with or without ulcer = foot X-ray AND MRI foot without and with contrast

If imaging is indeterminate, biopsy or aspiration is warranted

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

What is appropriate medical imaging?

Having been in radiology a number of years, I know it can be difficult to decide what is the best study, if any, for each patient. Radiation? Cost? Wait time? Contrast or not? MRI vs CT scan?

The American College of Radiology teamed up with many specialist to create the Appropriateness Criteria. It has the goal of helping providers better choose which study is best for their patients.

There is terrific information in this project, however it can be intimidating to navigate.

I will summarize a few per week, with links to the source documentation, as a primer for my friends who are not necessarily radiologists.

Fellow providers, please leave comments and I will address them to the best of my ability. Patients please see below.

This is the entire Appropriateness Criteria:

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

This is also accessible from here:

http://www.guideline.gov/search/search.aspx?term=acr+appropriateness



Radiologists in training may benefit from these posts as well as the ABR Core Exam asks specific question from the ACR AC.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Pulmonary hypertension?

Suspected pulmonary hypertension?

Summary

Suspected pulmonary hypertension =

Both echocardiography and right heart catheterization, next chest radiograph and CTA chest with contrast, if needed

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Pyelonephritis?

Acute pyelonephritis?

Uncomplicated patient = no imaging indicated

Complicated patient such as: diabetes, immunocompromised, prior renal surgery, prior stones or not responding to therapy = CT abdomen with, and possibly without, contrast (e.g. if history of stone), possibly renal ultrasound or MRI abdomen with contrast 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Knee Trauma

Acute knee trauma? - #orderwhat #kneepain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Acute knee trauma, fall or twisting injury with:

No focal tenderness or effusion and able to walk => no study indicated

Focal tenderness, effusion or unable to walk => X-ray then MRI if needed.

Suspect tibial plateau fracture on xray => CT knee

Suspect posterior dislocation => X-ray and MRI and possibly angiography. 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Dyspnea, suspected cardiac origin?

Dyspnea of suspected cardiac origin

Summary:

Chest xray and transthoracic echocardiography (possibly followed by a stress: echo, SPECT or PET or Cardiac MRI) 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Developmental dysplasia of the hip?

Developmental dysplasia of the hip

Summary:

Younger than 4-6 months with definite or equivocal physical exam findings = Ultrasound hips

Younger than 4-6 months, female, breech delivery or positive family history  without physical exam findings = Ultrasound hips

Older than 4-6 months with clinical suspicion (limited abduction or abnormal gait) = Single frontal AP hip radiograph 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Knee pain without trauma. Is there an effusion? Degenerative changes?

Imaging for knee pain without trauma. Is there an effusion? Degenerative changes?

Summary

Child, adolescent or adult knee pain without trauma = knee X-ray  

Child, adolescent or adult knee pain without trauma and knee X-ray is negative or shows effusion or secondary signs of trauma = MRI knee without contrast

Adult knee pain without trauma and knee X-ray shows avascular necrosis = possibly MRI without contrast if it directs therapy

Adult knee pain without trauma and knee X-ray shows degenerative changes, crystalline arthropathy or chondrocalcinosis = Probably NOTHING 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Acute hip pain, suspect fracture?

Imaging of acute hip pain, suspect fracture?

Summary:

First study middle aged or elderly = Xray hip, AP and cross table lateral and Xray pelvis, AP view BOTH

Negative or indeterminate radiograph, then = MRI hip/pelvis or CT hips

(Note if fracture and minimal trauma, eval bone density with DEXA scan)

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Imaging of solitary pulmonary nodule?

Imaging of solitary pulmonary nodule?

Summary:

Nodule discovered on chest radiograph, **greater** than 1 cm and low, moderate or high clinical suspicion for cancer = CT chest without contrast,  if CT indeterminate then PET CT whole body and biopsy if PET avid or enhances.

Nodule discovered on chest radiograph, less than 1 cm and low clinical suspicion for cancer = watchful waiting with CT follow up or CT chest without contrast (Note: Fleischner Criteria not addressed in this publication)

Nodule discovered on chest radiograph, less than 1 cm and moderate to hight clinical suspicion for cancer = CT Chest and possible biopsy or follow up CT chest.

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Acute chest pain, suspect pulmonary embolism?

Acute chest pain, suspect pulmonary embolism?

summary:

adult = chest X-ray and CTA chest, both

pregnant patient = chest X-ray, US lower extremity with doppler and possibly CTA chest or VQ scan  

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Jaundiced patient?

Imaging for jaundiced patient?

Summary: 

Abdominal pain with 1 of the following: fever, history of biliary surgery or known cholelithiasis = US abdomen (then CT ABD/PEL with contrast or MR Abdomen with contrast with MRCP)

Painless with 1 of the following: weight loss, fatigue, anorexia or symptoms greater than 3 months =  CT ABD/PEL with arterial and portal venous contrast, US abdomen or MR Abdomen with contrast with MRCP)

Clinical and lab exam makes obstruction unlikely = US abdomen (then MR Abdomen with contrast with MRCP, if needed) 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

LLQ pain suspected diverticulitis?

LLQ pain suspected diverticulitis?

Summary:

Diverticulitis, suspect complication or atypical presentation = CT ABD PEL with IV and Oral and/or colonic 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Headache in a child?

Headache in a child?

Summary:

Recurrent, including migraine, without permanent neurologic deficit or signs of increased intracranial pressure = probably nothing

Headache with permanent neurologic deficit or signs of increased intracranial pressure = MRI without (and maybe with contrast), CT, if MRI not available.

Abrupt onset, thunderclap, concern for vascular rupture = CT head without contrast (if subarachnoid, add CTA and maybe catheter angiography if available) 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon