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Transcript of Rads
Brief intro to ACR's Appropriateness Guidelines
Michael A. Cerasaro, PGY 1 364/365
Mitigate patient risk
Streamline diagnostic work-up
Economic implications of [over]-utilization of diagnostic radiology testing.
Previously healthy 56yo woman with new onset memory impairment.
- ED dept. ordered non-contrast CT of head
46yo, polysubstance abuse - IVDA, meth, BIB friend c/o slowly progressive decline
22yo, lives in college dorm, 3-4 day hx of N/V, photophobia, headaches, lethargy
86yo, with sudden onset memory loss and dysarthria, with left hemiparesis
The Proof in the Pudding:
1. No one actually likes pudding
2. Rad Rule of 10s
- 10% of total health care expenditures
(total expenditure 2014 ~ $3.0T, about $10,000 per person)
- 10% unnecessary/duplicate
3. Slowed growth rate, overall stable utilization
Age, ACA, CYA, Dr. Google, Clinical pressures, ***SELF-REFERRAL***
4. There's at least SOME good news?
Take home points:
Dx: Creutzfeldt-Jakob disease
All cases fatal, 90% mortality w/in 1yr
CT normal in 80% of cases
MRI typically demonstrates restricted diffusion and T2/FLAIR hyperintensities within the bilateral striatum, thalamus, and cortical gray matter.
55yo male presents to ED with diffuse abdominal pain. Currently undergoing peritoneal dialysis.
KUB ordered by ED physician
Current alcoholic, last drink was 2hrs PTA, diffuse pain but more RUQ
26yo female, sexually active
65yo smoker, mid-epigastric pain radiating to back
Adult with poor diet, frequent constipation, intermittent small volume hematochezia noted on TP and on stool
Hey! Over here!
T1: "anatomic", more approximate look at tissues and structures
FLUID DARK, FAT BRIGHT
w/ Gad: very bright on T1, highlights vascular structures, breakdown of BBB, meninges, tumors/abscesses
T2: FLUID WHITE
FLAIR - allows attenuation of CSF rendering it dark, better distinction btwn CSF and parenchymal edema - especially in PVWM.
DWI: "facilitated vs. restricted diffusion"
ADC: "apparent diffusion coefficient map" - reconstructed image without T2 input, represents actual diffusion - more objectively useful when looking for ischemia.
Take home points:
Dx: Mesenteric ischemia causing bowel infarction and perforation leading to...
1. Pneumatosis intestinalis
2. Presence of portomesenteric venous gas
Pneumatosis intestinalis may be a benign finding or may be secondary to significant intra-abdominal pathology, such as mesenteric ischemia.
Portomesenteric venous gas has multiple causes, the most serious and most common of which is mesenteric ischemia.
CT is most sensitive test for Pneumatosis intesitinalis. Also helpful for the detection of pneumoperitoneum and portomesenteric venous gas, as well as for elucidating the underlying causal pathology
A 43yo male presents to the ED with new-onset fatigue and dyspnea, intermittent non-productive cough.
ED physician ordered CXR
...but whaaaat if:
HIV pos, cough + sputum, CD4 165. Patient relates pruritus, on exam he has a multi-focal maculopapular rash
Adult male, c/o substernal chest pain radiating to back, 40 pack year smoking history
75yo female with vague chest pain, shoulder pain, dyspnea
27yo male, BIB co-worker after patient started complaining of R-sided CP and dyspnea