#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

Suspected Physical Abuse Child

2 years or younger? Over 2? Neurologic findings?  #NAT #orderwhat  @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

2 years old or younger, no focal neuro symptoms => Skeletal survey

2 or younger, head trauma with no focal neuro symptoms => Skeletal survey and non con head CT

2 or younger, WITH focal neuro symptoms => Skeletal survey and non con head CT, probably brain MRI

OVER 2, WITH focal neuro symptoms => Non con head CT, probably brain MRI

Any age with obvious chest, abdomen or pelvic trauma => Skeletal survey and indicated CT 

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

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

Acute pancreatitis? Ultrasound or CT? When?

#orderwhat #pancreatitis @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg #choosingwisely

Imaging for acute pancreatitis

First time presentation, abdominal pain, and increased amylase and lipase with high clinical certainty of diagnosis; LESS THAN 48–72 hours after onset of symptoms; clinical score irrelevant; 

unknown cause  => US abdomen to assess for gall stones

Everything else, probably => CT abdomen with contrast, see below.  

Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, acute physiology and chronic health evaluation [APACHE], bedside index of severity in acute pancreatitis score (BISAPS), and/or Marshall); GREATER THAN 48–72 hours after onset of symptoms. => CT abdomen with contrast

Continued SIRS, severe clinical scores, leukocytosis, and fever; >7–21 days after onset of symptoms. => CT abdomen with contrast

Initial presentation with atypical signs and symptoms, including equivocal amylase and lipase values (possibly confounded by AKI or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). => CT abdomen with contrast

Known necrotizing pancreatic and peripancreatic pancreatitis, significant deterioration in clinical status, including abrupt decrease in hemoglobin/hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells; time
after symptom onset irrelevant. => CT 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

Foot trauma? Foreign body? X-ray needed?

Acute foot trauma? - #orderwhat #footpain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Meet Ottawa Rules or not neurologically intact  => Xray

Concern for Lisfranc injury => Weight bearing Xray, if able or MRI foot

Does not meet Ottawa Rules => No study indicated

X-rays negative and concern for tendon injury or dislocation => MRI foot

Penetrating trauma and concern for foreign body => X-ray, then US 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

Ankle Trauma?

Suspect Ankle Fracture

Summary:

Ankle radiograph if patient meets Ottawa Rules: 

Can’t bear weight immediately after injury 

OR 

Point tenderness over medial malleolus, posteroinferior lateral malleolus, talus or calcaneus 

OR 

Cannot walk 4 steps in emergency department



If one of these describes the patient, an ankle radiograph is appropriate.

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

Neck adenopathy?

What to do with neck adenopathy?

Summary:  

Adult, afebrile, single or multiple node(s) =  CT neck with contrast (or MRI neck with contrast,  if needed*)

Adult, febrile, single node =  CT neck with contrast (or MRI neck with contrast,  if needed*)

Adult pulsatile neck mass = CTA and CT neck with contrast (or MRI neck with contrast,  if needed*)

Adult with cancer history and nodes = Neck PET and CT with contrast

Child (up to age 14), afebrile or febrile, single or multiple node(s) = Neck ultrasound (Then CT neck with contrast (or MRI neck with contrast,  if needed*))

* This decision is usually based on renal function and contrast reactions 

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

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