1. RADIOLOGY PRESENTATION SKILLS RADIOLOGY PRESENTATION SKILLS (THIRD YEAR SURVIVAL) Oral Formal or Informal

2. I know it’s your patient, but let’s see what our 3 rd year student thinks!

3. OMG ! I don’t know what to say!

4. I – IDENTIFY D – DESCRIBE E – EXPLAIN A - ACTION But…Dr. Roentgen has given me an I.D.E.A

5. I DENTIFY Who, 2 Why’s and a What Who --- is the patient? 55 yo aaf with a history of heart disease. ie-sex, age, ethnicity and pertinient history Why --- Chief complaint She comes to the ED with complaint of SOB. What --- What image are you looking at? This is a frontal projection of a chest xray. Why --- Indication for the exam. SOB

6. D ESCRIBE EXAM QUALITY FINDINGS EXAM - Describe the exam and any details of how it was performed. ie-- AP portable chest x-ray done today in the ICU ie-- Multiple sections from a CT exam of the abdomen available – IV contrast was administered. Number of images Single or multiple Prior films for comparison ie--There is an upright PA and Lateral chest x-ray done yesterday for comparison.

7. DESCRIBE EXAM - QUALITY- FINDINGS ( Inspiration, Position, Exposure) Inspiration–Adequate or decreased. Poor is not a good descriptive choice. Remember: The patient is sick, the technologist gets the best film possible, and you weren’t there.

8. Position – Satisfactory positioning or note rotation by clavicle position compared to the midline spinous process. * If clavicles project higher than the ribs its lordotic angulation * PA will have less magnification of the heart than an AP * If it is a portable---it’s an AP * If there is a lateral view ---it’s a PA * If you can’t tell---say FRONTAL DESCRIBE EXAM- QUALITY - FINDINGS (Inspiration, Position, Exposure)

9. Adequate or satisfactory are good terms to use. Penetration- is also a term used to describe exposure. This is assessment of overall whiteness or darkness of the image. Underexposure- image is too white (not enough photons) This limits evaluation in retrocardiac region and can simulate CHF or interstitial disease. Overexposure- image is too dark. This can limit evaluation in the periphery of lung field especially for nodules and pneumothorax. It can also simulate COPD. DESCRIBE EXAM - QUALITY - FINDINGS (Inspiration, Position, Exposure)

10. DESCRIBE EXAM - QUALITY- FINDINGS Depending on Attending physician’s preference: Formal recitation of reading the chest x-ray or Description of dominant positive findings Some attendings prefer a specific format when reading a chest x-ray Know: Formal or informal—Which is appropriate for the situation You can obtain this info from observations of other students, interns and residents.

11. A good habit is to start by describing post–op changes, support catheters and devices. *Note the distal location of the device / catheter ***MALPOSITION OF LINES AND CATHETERS IS OFTEN OVER LOOKED DUE TO PATHOLOGY ON THE IMAGE. Terms for catheter / device description: examples… … The ET tube is above the carina … Central catheter enters on the left extending to the SVC … Post-op changes from mediastinal surgery are seen. NOTE TO SELF!

12. DESCRIPTIVE TERMS FOR NORMAL CHEST EXAMS CHEST WALL- There is no soft tissue abnormality / pathology. SKELETAL - No traumatic or destructive lesions are seen. (note-degenerative changes in spine) HEART SIZE - The cardiac silhouette is within normal limits. MEDIASTINIUM - There is no mass or abnormality. HILA - There is no hilar mass or suspicious adenopathy. PULMONARY VASCULARITY- Is not engorged. LUNGS - Show symmetric ventilation without mass or consolidation. PLEURA - Shows sharp costophrenic angles without effusion.

13. PATHOLOGY DESCRIPTION Use this phrase and fill in the blanks There _ * _ a/an ______ of ________density located______ which is of _______size And shows ______shape and ________margin. *is *are Let’s choose is There is an ______ of ________density located______ which is of _______size And shows ______shape and ________margin.

14. There __ a/an _ * __ of _______density located______ which is of _______size and shows ______shape and ________margin. *Area *Region *Zone *Focus *Nodule Let’s choose area There is an area of _______density located______ which is of _______size and shows ______shape and ________margin.

15. *increased *decreased *mixed *homogeneous *heterogeneous There __ a/an ___ of _ * __density located______ which is of _______size and shows ______shape and ________margin. Let’s choose mixed There is an area of mixed density located______ which is of _______size and shows ______shape and ________margin.

16. There is a ______ of ________density located___ * ___ which is of _______size and shows ______shape and ________margin. *projecting over *in the region of *lateral / medial to *extending from “X” to Y There is an area of mixed density located in the region of the Lt. lower lobe which is of _______size and shows ______shape and ________margin. Let’s choose In the region of & Lt. lower lobe *in the Rt. / Lt. chest hemithorax lung lobe

17. * Large *Moderate *Small *Approximately 3cm in diameter or 3 to 4 cm in diameter Note--rib width serves as a 1cm measurement There is a ______ of ________density located______ which is of ___ * ____size and shows ______shape and ________margin. Let’s choose “moderate” There is an area of mixed density located in the region of the Lt. lower lobe which is of moderate size and shows ______shape and ________margin

18. There is a ______ of ________density located______ which is of _______size and shows __ * __shape and ________margin. *round / rounded *lobular *oval *triangular *irregular *wedge shaped Curvilinear is a universal descriptor that fits about any shape other than straight Let’s choose irregular There is an area of mixed density located in the region of the Lt. lower lobe which is of moderate size and shows irregular shape and ________margin

19. *sharply defined * ill defined There is a ______ of ________density located______ which is of _______size and shows ____shape and ___*__margin. Let’s choose sharply defined There is an area of mixed density located in the region of the Lt. lower lobe which is of moderate size and shows irregular shape and sharply defined margins. Whew!

20. E XPLAIN C ompare Is there change from a previous exam. State your interpretation of the significance of the findings. Discuss diagnosis and differential Example I would be concerned about ___ I think this is____ I would have to consider____ Start by stating the most likely first. Mention the most significant that would be considered with this history and exam. Think in terms of general pathologic topics. Infection, Neoplasm, Cardiovascular, Trauma

21. What are you going to do? observe compare with old studies repeat / new studies interventions lab studies additional physical exam Example: * Plan to discuss with radiology about performing a percutaneous biopsy. * Check to see if there are other previous exams. A CTION

22. PEARLS Best film is the previous film Hazy, ill defined, cloudlike, fluffy-------air space disease Linear, reticular,coarse,-----interstitial disease ? Nodule-----repeat chest with nipple markers ? Pleural effusion----Decubitus film ? Apical disease----Lordotic film Portable film----Repeat in department asap ? Retrocardiac mass----barium study---hiatal hernia Chest wall lesion----get rib detail film ? Pneumothorax---get expiration film Trace tubes & lines with your finger if exact position is not clear, tip is where problems arise. Et tubes go distal into Rt. mainstem often. Practice finding carina. Rib height = 1cm--- Vertebral body=3cm If it is calcified, goes away or remains stable over time = benign Make statements—don’t ask questions---Watch tone of voice! Think simple, cheap, and safe as first step. Be as general as you have to be and as specific as you can be. X-ray / CT---------------------------density Ultrasound----------------------echogencity / anechoic Nuclear medicine------------intensity / activity MR------------------------------------- intensity / signal