Post on 14-Aug-2020
HOW TO MAXIMIZE YOUR TELERADIOLOGY *RELATIONSHIP*
ELI B. COHEN, DVM, DACVR CLINICAL ASSISTANT PROFESSOR
NC STATE COLLEGE OF VETERINARY MEDICINE
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COMMON IMAGING MISTAKES
(TELE)RADIOLOGIST’S LAMENTS
NO/LACK OF CLINICAL HISTORY
POSITIONING
Rotated/oblique cervical/spinal radiographs
Orthogonal views!
Left lateral view of abdomen*
TECHNIQUE
Quantum mottle
Saturation artifact
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CLINICAL HISTORY
CONTEXT IS CRITICAL!
Image interpretation is a noise limited decision task
Decisions are a cognitive process, heavily reliant on clinical context
Each modality has it’s own sensitivity/specificity
It is often the history which alters differentials (which illness scripts are kept or discarded)
No/incomplete clinical history
Strips the expert of their expertise
Creates image interpreter instead of a clinician consultant
Constructing a ddx list prior to imaging/submission passes the case through a cognitive filter before it gets to the radiologist (inherent double read)
nical conte tttxttt
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TARGET KNOWLEDGE
I’M LOOKING FOR MY CAR…I’M LOOKING FOR MY TWO-DOOR CAR…I’M LOOKING FOR MY ORANGE TWO-DOOR CAR…
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Target Knowledge5
FAN OF EASTERN MEDICINE?
CLINICAL HISTORY - THE FUNNY6
IRONY
CLINICAL HISTORY - THE FUNNY7
COMMUNICATION IS KEY
zzzzzzzz
CLINICAL HISTORY - THE FUNNY8
THE NEW PLANKING?
CLINICAL HISTORY - THE FUNNY
+ + = ????????????
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PUNCTUATION ALWAYS WELCOME
CLINICAL HISTORY - THE FUNNY10
VETERINARY STEPHEN KING
CLINICAL HISTORY - THE FUNNY11
CHICKEN OR THE EGG
CLINICAL HISTORY - THE FUNNY12
IMAGING IN THE 4TH DIMENSION
BACK TO THE FUTURE
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LETTER SOUP (BOWL)
LETTER SOUP (CUP)
CLINICAL HISTORY - THE BAD14
HAIKU?
CLINICAL HISTORY - THE BAD15
WHAT’S THE QUESTION?
CLINICAL HISTORY - THE BAD + SAD16
CLINICAL HISTORY - THE BAD17
CLINICAL HISTORY - THE BAD18
CLINICAL HISTORY - THE BAD19
CLINICAL HISTORY - THE BETTER20
CLINICAL HISTORY - THE BETTER21
CLINICAL HISTORY - THE BETTER22
CLINICAL HISTORY - THE BETTER23
CLINICAL HISTORY - THE GOOD24
CASE 3
WHY COUGH W/ HEART DISEASE?
•Ferasin, L., et al. Risk factors for coughing in dogs with naturally acquired myxomatous mitral valve disease. JVIM, Vol. 27, Iss 2; 2013
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CLINICAL HISTORY - THE BEST
Signalment
Presenting complaint
Pertinent clinical history
Your clinical differentials
Any specific questions you have
“Is there cardiogenic edema/LCHF”
“What’s the round opacity over the 4th rib on the left lateral?”
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COMMON IMAGING MISTAKES
(TELE)RADIOLOGIST’S LAMENTS
NO/LACK OF CLINICAL HISTORY
POSITIONING
Rotated/oblique cervical/spinal radiographs
Orthogonal views!
Left lateral view of abdomen*
TECHNIQUE
Quantum mottle
Saturation artifact
blogs.thegospelcoalition.org
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POSITIONING - NECK
CERVICAL RADIOGRAPHS
If the dens looks great, the rad’s not straight!
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LOOK MA, NO DENS!
POSITIONING - NECK29
POSITIONING - NECK30
POSITIONING - NECK31
POSITIONING - NECK32
POSITIONING - THORAX
COMPLETE EXAMINATION
At least 2-views, 3-4 views should be standard
Left lateral, right lateral, ventrodorsal, dorsoventral
DV if patient is unstable
Different views show different things!
Maximal inspiration
Be aware of position prior to imaging
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POSITIONING - THORAX
CAUDAL LOBES ARE THE MEATIEST!
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POSITIONING - THORAX
EXP INSP
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POSITIONING - THORAX36
POSITIONING - THORAX37
POSITIONING - THORAX38
WHAT’S YOUR DIAGNOSIS?
POSITIONING - THORAX
L
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POSITIONING - THORAX
RR
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POSITIONING - THORAX41
WHAT’S YOUR DIAGNOSIS?
POSITIONING - THORAX
R
42
POSITIONING - THORAX
L
L
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POSITIONING - THORAX
L
R
R
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WHY IS THERE DISTANCE BETWEEN HEART AND STERNUM?XR
POSITIONING - THORAX45
POSITIONING - THORAXOSIOSITIONTIONINGING TH- THTHORAXORAXORAXORAXORAXORAXORAXRAXRAXAXAXX46
MEDIASTINAL SHIFT
218044
Volume Loss
POSITIONING - THORAX47
PRE POST
POSITIONING - THORAX48
ATELECTASIS VS. CONSOLIDATION
POSITIONING - THORAX49
DOWN PATHOLOGY RISES
POSITIONING - THORAX50
POSITIONING - THORAX51
POSITIONING - ABDOMEN
COMPLETE EXAMINATION
At least 2-views, 3-views should be standard
Left lateral, right lateral, ventrodorsal
DV useless unless looking at stomach or contrast study
12-24hr fast (rarely happens)
Always surveys before a contrast study
Be aware of prior medications
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GRAVITY + RECUMBENCY + ANATOMY = DXPOSITIONING - ABDOMEN
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POSITIONING - ABDOMEN54
POSITIONING - ABDOMENTEXT
F/B
P
F/B
P
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RIGHT
LEFT
POSITIONING - ABDOMEN
PF
B
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P
BF
RIGHT
LEFT
POSITIONING - ABDOMEN57
POSITIONING - ABDOMEN
RIGHTLEFT
P B
F
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RIGHT LEFT
F
BP
POSITIONING - ABDOMEN59
POSITIONING - ABDOMEN60
POSITIONING - ABDOMEN
START WITH LEFT LATERAL!
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COMMON IMAGING MISTAKES
(TELE)RADIOLOGIST’S LAMENTS
NO/LACK OF CLINICAL HISTORY
POSITIONING
Rotated/oblique cervical/spinal radiographs
Orthogonal views!
Left lateral view of abdomen*
TECHNIQUE
Quantum mottle
Saturation artifact
www.other-worlds-cafe.com
62
low contrast
Diagnostic contrast
TECHNIQUE63
HIGH contrast
Diagnostic contrast
TECHNIQUE64
WHAT INFLUENCES CONTRAST?
Subject Contrast
Density
Thickness
Atomic number
Film/Image Detector Contrast
XR Beam Energy
As kVp increases, object contrast decreases
Fog/Scatter
Increases overall opacity, but decreases contrast
Signal:Noise ratio*
Reduced by: collimation, decreasing kVp, using grids*
Motion*
TECHNIQUE 65
TECHNIQUE - QUANTUM MOTTLETECHNIQUE
PENNIES IN THE HATBOX
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PENNIES IN THE HATBOX
TECHNIQUE - QUANTUM MOTTLE67
TECHNIQUE - QUANTUM MOTTLE
PENNIES IN THE HATBOX
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TECHNIQUE - QUANTUM MOTTLE69
WHAT’S THE FIX?
We need more pennies (photons)!
Primary determinant of photon # = mAs
Need to double mAs to see effect
TECHNIQUE - QUANTUM MOTTLE70
TECHNIQUE - OVEREXPOSURE71
TECHNIQUE - OVEREXPOSURE72
SATURATION ARTIFACT
TECHNIQUE - OVEREXPOSURE73
SATURATION ARTIFACT /
PLANKING
TECHNIQUE - OVEREXPOSURE74
WHAT’S THE FIX?
TECHNIQUE - OVEREXPOSURE
Reduce technique (kVp)
Adjust for thinner/thicker parts of the patient
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CLINICAL HISTORY - POSITIONING - TECHNIQUE
CONCLUSION - THIS IS AN IMPERFECT *RELATIONSHIP*
76
FIN
QUESTIONS???
Hx: None provided.
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