Senior Modules The Fundamentals of Radiology in Family Medicine Before You Begin

This module, intended for fourth year medical students and interns, assumes familiarity with fundamental anatomy, imaging, and pathology concepts.

Please review our website sections: • “Anatomy” • “Radiology-Pathology” • “Interpretive Skills” If you need to learn or review these core concepts prior to initiating this senior module

If material is repeated from another module, it will be outlined as this text is so that you are aware Introduction

• Please switch to presentation view for optimal educational experience – There are animations and timed bullet points to test your thought process – These will only appear properly when viewed in slide show presentation • This module is not intended to teach you everything there is to know about radiology – When questions arise always feel free to ask your friendly radiologist! • This presentation is designed to focus on primary care and screening topics frequently encountered in Family Medicine • Acute and hospital care is covered in our other presentations Table of Contents Click on the title to jump to that section • Part I: Vocabulary • Part II: Concepts • Imaging Modalities • Radiation Safety • Patient Education • Part III: Cases • Back pain • Shortness of breath • Headache • Arthritis • Thyroid disease • Screening Vocabulary Cardiothoracic Ratio

• Ratio of the widest transverse diameter of the heart (A) compared to the widest internal diameter of the rib cage (B) • Cardiothoracic ratio = A A/B B • In a normal adult with proper inspiration the ratio should be less than 50% Greater than 50% is defines cardiomegaly, as seen in this case Ectatic and Tortuous Aorta • Ectatic aorta is an aorta which is dilated • Tortuous aorta is an anatomical abnormality where the aorta takes a distorted shape or path – These are commonly seen in patients with hypertension and/or atherosclerotic disease

Tortuous path Septal Lines • Short parallel lines at the periphery at right angles to the pleura • Represent interlobular septa filled with fluid, a finding of CHF • Seen in pulmonary interstitial edema and formerly referred to as Kerley B lines

Fluid fills the lymphatic spaces in the interlobular septa creating the septal lines seen in CHF

Pulmonary Artery Pulmonary Vein Alveoli Lymphatics Air Bronchogram • The visibility of air in the bronchus because of surrounding airspace disease/consolidation • Seen here in both a chest x-ray and CT of the same patient Honeycombing • Small cystic spaces seen in idiopathic pulmonary fibrosis • Typically seen in the lung bases and peripherally in a subpleural location • Term used very carefully and specific to ILD • An opacity within the lung which is less than 3 cm in widest diameter • Sometimes hard to see on Chest X-ray, better appreciated on CT Lung Mass • Opacity in the lung which is greater than 3 cm in diameter • Notice the cystic changes compatible with COPD on the CT • Patient likely a smoker increasing his risk for lung cancer

4.2 cm Atelectasis • Loss of volume in some or all of the lung, usually leading to increased radiodensity of the lung involved • Signs of atelectasis include displacement of the interlobar fissures toward the area of atelectasis and increase in density of the affected lung

Displacement of the mobile structures of the thorax including the trachea, heart and hemidiaphragms can be seen toward the side of atelectasis Pleural Effusions and the Meniscus Sign

• Pleural fluid rises higher along the lateral margin of the thorax than it does medially • How much fluid must be in the pleural space to cause blunting of the costophrenic angle in a PA chest radiograph? – Approximately 300 mL

Loculated indicates that the Real life meniscus with fluid is confined to a fixed pocket within the fluid climbing up the pleural space walls of the glass The Silhouette Sign • Loss of an expected silhouette on chest X-ray as a result of adjacent opacification of lung • Notice on the chest X-ray that the right heart border is no longer visualized

Air Bronchogram* Tree-in-bud Pattern • Represents bronchial luminal opacification with , pus, or fluid • The normally invisible peripheral airway takes on the appearance of a budding tree

Infection is the most common cause of a tree in bud pattern Ground Glass Opacity

• Hazy area of increased attenuation in the lung with preserved bronchial and vascular markings • Looks as though a piece of ground glass has been placed over normal lung Bowel Distention • Can be normal • When the bowel lumen is completely filled with air but is not expanding beyond its normal caliber Bowel dilation

• When bowel is filled with air beyond it’s normal size • Small intestine is usually less than 3 cm • Notice the contour of the bowel wall which indicates we are seeing air within the small bowel Ileus

• Ileus is hypomobility of the GI tract in the absence of bowel obstruction • Characterized as localized ileus or generalized adynamic ileus Localized ileus • Focal irritation of loops of bowel from adjacent inflammation of visceral organ • Examples include cholecystitis, pancreatitis, appendicitis, and diverticulitis

Localized ileus and bowel dilation from underlying pancreatitis Generalized Adynamic Ileus • The entire bowel is aperistaltic or hypoperistaltic • Swallowed air dilates and fill loops of small and large bowel • Almost always a result of pelvic or abdominal surgery where the bowel is manipulated Dilated loops of small and large bowel

Air under the diaphragm provides more evidence that the patient is post operative Small Bowel Obstruction • A lesion either on the inside or outside of the small bowel obstructs the lumen • Proximal to the obstruction the small bowel dilates and distal to the obstruction the lumen collapses with no air in the rectum or sigmoid Continued peristalsis proximal to the obstruction creates a pressure gradient to produce uneven air fluid levels

Notice multiple air Relative absence of fluid levels distal gas, is associated with a point of transition Large Bowel Obstruction

• A lesion either on the inside or outside of the colon causes an obstruction of the lumen • Usually no air fluid levels in the obstructed colon and causes distal collapse of the large bowel lumen

Patient obstructed from massive constipation Pneumatosis Intestinalis • Air within the bowel wall itself • Caused by obstructive and necrotizing disease • Necrotizing enterocolitis, ischemic bowel disease, Hirschsprung’s disease, obstructing carcinomas Extravasation • When intraluminal contrast escapes to an undesired location. • This can occur when iodonated contrast escapes a blood vessel or when barium escapes the GI tract • Old barium in the peritoneal cavity seen wrapping around the • Confirmed on CT of the abdomen

It is critical to use soluble contrast if perforation is a concern as extravasated barium in the peritoneal cavity can cause peritonitis Dystrophic Calcification • Calcification occurring in degenerated or necrotic tissue • Commonly seen in atherosclerotic arteries, cysts

Calcium deposited in the wall of the aorta Stranding

• Haziness and radiopaque linear extension from a source of inflammation – commonly seen on abdominal CTs

Peri-appendiceal fat stranding in acute appendicitis Dislocation Vs. Subluxation

Dislocation: Complete Subluxation: Incomplete disruption of a joint disruption of a joint (ie. Partial dislocation) Effusion

• An effusion is the abnormal accumulation of fluid (e.g. serous, sanguinous, purulent, chylous, etc) in a body cavity, such as a joint space, the pleural space, or the pericardial space • Joint effusions occur when an increased amount of fluid accumulates in the synovial compartment • Joint effusions can occasionally be palpated on physical exam, but can consistently be identified radiographically Osteopenia Vs. Osteoporosis

• Age related decrease in mass increasing the risk for fracture

• Dexa Scan (Dual EnergyImages Xray Absorptiometry) from a DEXA scan measures bone mineral density (BMD) and allows calculationused to of measure T score BMD of the femoral neck and lumbar • T score: Standard deviationvertebrae from the mean BMD of a 25 yo female

• Osteopenia: T score of -1 to -2.5

• Osteoporosis: T score of > -2.5 Sprain vs. Strain

Sprain: A torn ligament, as in the MCL Strain: A torn muscle, as in the teres pictured above. minor muscle pictured above. Both are best observed by MRI Stages of Healing

Notice the old healing fx that has calcified in the superior pubic ramus.

Appreciate the sharp edge typical of acute fractures

The hazy appearance around the fx represents callus formation which is suggestive of a subacute time course. Acute Subacute Chronic Hounsfield Units • The radiodensity of a field of interest within a CT scan – The more dense the tissue, the more X-rays that are stopped during CT acquisition – The higher the attenuation (also referred to as density) of radiation, the higher the Hounsfield units – By convention water is set to 0, air is -1000, bone is ~1000 – The Hounsfield scale is useful for identifying different tissue types Ionizing Radiation

• Radiation capable of ionizing (i.e. removing electrons from) atoms • Human cells exposed to ionizing radiation are susceptible to varying amounts of damage, depending on various factors including: • The dose of ionizing radiation received • The type of cells exposed

• Dose, in medicine, is usually reported in “Sieverts” • Sievert, as opposed to other units such as Gray, takes into account the biological impact of differing types of ionizing radiation (i.e. alpha, gamma, etc.) CT Windowing

• The window width describes the range of Hounsfield units which are displayed • The narrower the window results in greater contrast between each shade of grey • The window level describes which Hounsfield unit will be displayed as the middle shade of grey • Any window width and level can be assigned when viewing a CT, but certain pre-programmed window settings tend to highlight pertinent anatomy Lung window Soft tissue window Bone window

Window width: 2000 HU Window width: 400 HU Window width: 2000 HU Window level: -450 HU Window level: 40 HU Window level: 300 HU

- 2000 HU 0 HU 2000 HU - 2000 HU 0 HU 2000 HU - 2000 HU 0 HU 2000 HU Common MRI Sequences • T1 T1 T2 – Water is dark relative to bright fat, good for anatomy • T2 – Water is bright and fat is bright, good to assess edema and/or pathology • FLAIR (Fluid Attenuated Inversion Recovery) FLAIR Diffusion – Free water is dark while edema and pathology is bright which makes this sequence particularly valuable in neuroimaging • Diffusion CSF is dark on T1 and bright on T2 – Restricted free water shows up as bright STIR which is useful in the diagnosis of CVA Proton Density • STIR (Short TI Inversion Recovery) – A T2 weighted image with inherent fat These are normal scans to suppression which is valuable when illustrate the sequences examining • Proton Density – Weakly T2 weighted, water is gray, good for tendons, ligaments, and cartilage Concepts Interpreting Chest Radiographs Basics of chest radiograph interpretation Initial step --> Quality check

• Penetration - Should be able to see the spine through the heart • Inspiration - Should see at least eight to nine ribs • Rotation - Spinous process should fall equidistant between the medial ends of the clavicles • Magnification - AP films (notably portable films) will magnify the heart • Angulation - Clavicle normally has an “S” shape and superimposes on the third or fourth rib 10 places to look in a chest X-ray

• There is no correct order for reading a chest X-ray • Find the method you feel most comfortable with and be systematic 1. Lines and Tubes

• Make sure you explain each identified device • Trace hardware as it enters the patient to its termination • Confirm the device overlies expected anatomic landmarks 2.

• Look for symmetry in lung size and aeration (opacities and vascularity) • Scan the lungs from top to bottom comparing the upper and lower zones • Any diffuse or focal opacities (interstitial or airspace)? • Are the pulmonary vessels normal? – Increased/decreased in diameter or number? – Do the vessels taper as you reach the lung periphery? 3. Airway

• Trace the trachea and bronchi • Any airway deviation? 4. Pleura

• Any thickening or masses along the expected coarse of the pleura? • Are sharp costophrenic angles present • is fluid in the pleural space blunting the angle? 5. Hila

• Check symmetry and appearance of the hila • left should be higher than right • Superimposed vessels should be clearly identifiable • AP window

Comparison with prior studies assists in appreciating subtle changes 6. Mediastinum • Look for deviation or widening of mediastinum – Normal – Widening is defined as greater than 8 cm at the level of the carina 8 cm 7. Diaphragm

• Evaluate diaphragm for clarity and position • Vessels should be identified representing aeration in the posterior and inferior lung 8. Cardiac • Assess heart contours • Enlargement, symmetry, effusion • Evaluate the heart size using the cardiothoracic ratio* • Investigate cardiac calcifications 9. Bones

• Trace individual ribs, spine, and clavicles • Assess for fractures, dislocations, and arthritis • Look for lytic and/or sclerotic lesions 10. Soft tissues

• Enteric abnormalities • Hernias, obstruction, abnormal gas pattern • Free air under the diaphragm • Breasts  postsurgical changes • Clips, asymmetry, absence Describing Fractures • Having a systematic approach to describing fractures (and any radiologic findings) is critical for reliable communication between physicians. • By convention, the proximal fragment is considered “anchored.” Describe the location of the distal fragment in relation to the proximal fragment. (Laterally displaced ulnar styloid = the ulnar styloid is laterally displaced in relation to the proximal ulna). • Below is an example of a system for describing fractures in a systematic fashion: • Fracture type (transverse, oblique etc.) • Comminuted ? • Location • Right or left • Relation of distal fragment (displaced, rotated, angulated, shortened) • Open? • Example: “An oblique, comminuted fracture of the distal 3rd of the right tibia with 1cm of lateral displacement.” Transverse

A fracture perpendicular to the axis of a long bone. Oblique

A fracture oblique to the axis of a long bone. Spiral

Such a fracture should make you suspicious for abuse, as the twisting necessary to cause this fracture generally does not occur in accidental trauma.

A fracture in which part of the bone has been twisted. Buckle (aka Torus)

• Compression fracture causing the bone to buckle to one side; most commonly found in a pediatric patient Greenstick

• Incomplete fracture resulting in only one cortex being violated; most commonly found in a pediatric patient Comminuted

A fracture which contains at least 2 intersecting fracture planes, and usually contains multiple pieces. Displacement

These bones are not just out of place, but there is actual side-to- side movement.

A fracture where the fractured pieces are moved and no longer lineup properly. Impaction

Generally impactions occur with this type of force.

A fracture where bone parts are driven into each other. Overlap

A fracture where bone parts have intersecting planes. Angulated

This fracture angulation can be described as being: 1) apex lateral or 2) medially angulated depending on the convention at your institution

A fracture where bone parts are end up in an angular distribution. Distracted

A fracture where bone parts are separated from each other in space. Cortical Discontinuation • Following the lines of the cortex of bone can help distinguish normal anatomy from pathology such as fracture or destruction.

Appreciate the smooth contour of the 4th metatarsal and proximal phalanx.

Now appreciate that the bony cortex is no longer present in the 4th digit indicating that the bone has been eaten away in this case of osteomyelitis. Simple (closed) vs. compound (open) fracture

• Simple (closed): A fracture that does not break the skin

• Compound (open): A fracture that breaks the skin • Associated with higher infection risk and usually requires surgical irrigation and debridement Screening Guidelines • Family medicine physicians are responsible for the long- term care of their patients, which includes screening for age-appropriate pathology which may involve imaging • Knowledge of screening guidelines is critical to ensuring early detection of actionable pathology without over-use of limited resources

• The United States Preventative Services Task Force publishes evidence-based screening recommendations often used by physicians to guide their clinical decisions • Grade A/B practices are recommended • Grade C practices should only be offered to select patient populations • Grade D practices are not recommended • Grade I practices do not yet have sufficient evidence to garner a positive or negative evaluation

• In the following slides, USPSTF imaging relevant screening guidelines will be reviewed USPSTF Grade A/B Imaging Recommendations • Annual screening of adults aged 55-80 who have 30 pack-year history of smoking, and are currently smoking or have smoked in the last 15 years, for lung cancer with low-dose CT • Can discontinue after an individual stops smoking for 15 years

• Screening women >65 years of age or at increased risk for osteoporosis with bone measurement (i.e. DEXA) for fracture prophylaxis

• Screening a single time men aged 65-75 who have ever smoked for abdominal aortic aneurysm with ultrasound

• Screening women aged 50-74 every 2 years with mammography for breast cancer Radiation Safety Radiation Safety

Family medicine physicians are often “gatekeepers” to imaging, and must weigh the benefits vs. risks of ordering a particular study. They may also need to address patients’ concerns regarding radiation.

The following slides will provide an overview of:

• ALARA • Radiation Exposure • Contraindications • Protection Radiation Safety Principles: ALARA (as low as reasonably allowed)

• Time: • less time around radiation decreases exposure • Distance: • Increasing distance from radiation source decreases exposure. Doubling distance from the radiation source decreases the exposure to ¼. • Shielding: • Appropriate shielding minimizes exposure. Tissue Effects of Radiation

• Not all tissues are effected the same • Tissues with higher rates of cell turnover are at greater risk of radiation damage • Radiation risk is estimated from population studies following nuclear bomb and nuclear reactor exposures. True risk is unknown, so physicians must balance risk with benefit. Minimize ionizing radiation

Certain populations are at higher risk from radiation exposure, which must be considered when ordering a study:

• Pregnant women • Children • Patients with high lifetime radiation exposure Perspective

Every year, and individual receives approximately 2.5 mSv of background radiation.

• Chest X-ray = 0.1 mSv • Chest CT = 7 mSv • DEXA Scan = 0.001 mSv • Mammogram = 0.4 mSv • Abdomen and Pelvis CT WWO = 20 msV Patient Education

• Ask for help! • Radiologist are there to answer questions! • You are your patient’s best source of information; make sure they understand the reason for the imaging, the procedure, the risks involved, and the benefits to be gained Cases A 42 yo M presents to urgent care with acute onset lower back pain

• What are some of the so-called “red flags” that would prompt immediate imaging instead of conservative management?

 Inability to urinate or defecate  Trauma  History of cancer  Unexplained weight loss  History of Osteoporosis  IV drug abuse  Signs of infection  Neurologic deficits  Previous lumbar surgery  Age >70

• What imaging modality would you get if one of these was present?

 MRI is the modality of choice. MRI shows the following in a patient with neurologic deficits and the inability to urinate…

• What is it?  Cauda Equina Syndrome

• The arrow points to the cauda equina, which looks to be compressed by spinal stenosis at the L4 level. This is likely a result of infiltration or expansion of the L4 vertebral body.

 This person would require immediate surgery. A 40 yo M comes in with low back pain for 3 days after helping his brother move? • What imaging study should you order to better characterize the pain? • Nothing! Without red flags, acute low back pain does not require diagnostic imaging • Which red flags would make you consider imaging • Unexplained weight loss, unexplained fever, immunosuppression, history of cancer, IV drug use, focal neurologic defects, duration of symptoms longer than 6 weeks • Let’s say that our patient has an unexplained fever in addition to low back pain. Which study should you order? • An MRI of the lumber spine with and without contrast Our patient’s MRI of the lumbar spine • Do you see a reason for T1 pre- T1 post- contrast contrast your patient’s symptoms with fat suppression on these pre/post contrast T1 and T2 weighted images?? • The patient has osteomyelitis of L2 and L3 T2 with abnormal T2 signal intensity and epidural extending into the psoas • Notice the increased blood flow to the surrounding vertebrae Additional Pathologies to Consider in Back Pain Herniated Disk

• Conservative treatment for 4-6 weeks • No imaging needed unless red flags or symptoms of spinal cord impingement • May see: • positive straight leg raise • Radiation of pain down the back of the leg • Pain increased with sitting • MRI can show soft tissue (intervertebral disk) abnormalities Spinal Stenosis • Leg pain is greater than back pain • Pain increases with walking/standing, improves with rest • Often seen in older patients • Conservative treatment 4- 6 weeks • Image if red flags, signs of spinal cord impingement or no improvement Metastatic Disease

• History of CA • Most common are prostate, breast, lung, thyroid, CA • Pain wakes from sleep • Recent weight loss, fatigue • Pain worsens in prone position • Spinous process tenderness • MRI can show soft tissue (spinal cord) abnormalities Compression Fracture

• Point tenderness • Loss of height • Most often due to osteoporosis • Can use X-ray to diagnose • MRI/CT can be used to better characterize etiology if in doubt Ankylosing Spondylitis

• Inflammatory Seronegative arthropathy (rheumatoid factor negative) • Bamboo spine: intra-articular bridging • Spinal stiffness, decreased range of motion • Sacroiliac sclerosis • Extra axial symptoms can be seen • Uveitis • Cardiac or pulmonary involvement • Can diagnose longstanding disease by x-ray • CT/MRI can also be used in diagnosis A 70 yo F comes in with a productive cough, chest pain and dyspnea

• You suspect a pneumonia • Which radiologic test should you order? • PA and lateral chest radiograph • Be sure to order the lateral chest radiograph as well if the patient can tolerate the exam • The lateral helps localize/triangulate an opacification and provides a better view of the retrocardiac air spaces Our patient, what is the diagnosis?

The patient has a pneumonia

Using the silhouette sign*, which lobe is the pneumonia in?

Right middle lobe Notice how it blurs the right heart border

The minor and major fissure are easily seen on the lateral because the infection outlines them What if instead our patient had this radiograph?

• Notice the fine, interstitial pattern of opacification in the lungs • This is consistent with an interstitial pneumonia which tend to involve the airway walls and alveolar septa • The prototypical interstitial pneumonias are mycoplasma pneumoniae and pneumocyctis jiroveci • Viral pneumonia may also produce this pattern When to image shortness of breath • Most pulmonary concerns start with PA and lateral chest x-ray • After radiographs, CT can be used to better characterize lung pathology if needed • Image when concerned for pneumonia, pneumothorax, pleural effusion or unknown pathology • Also consider imaging in respiratory illness in a patient over 40, patients with dementia or immunocompromised • You do not need to image uncomplicated asthma or COPD A 40 yo M comes in with chronic dyspnea

• He has had a cardiac workup at an outside hospital including normal transthoracic echocardiography • What radiologic test should you order? • PA and lateral chest radiographs What is causing his dyspnea?

• No obvious lung pathology • Heart is within normal limits which is consistent with his heart work-up at an outside hospital • Mild increase in interstitial lung markings

• What do you do next? • Does the patient need further radiologic work-up? • If so, which study should you order? Yes, the patient needs further workup

• Which study will allow for highest sensitivity to detect pulmonary pathology? • The patient needs a high resolution CT of the chest • High resolution refers to the fact that thinner slices are obtained to provide greater detail of the lungs • Do you need contrast for this exam? • No, to visualize lung pathology contrast is not needed due to the high contrast provided by air in adjacent structures • If you are looking for pathology within the mediastinum, such as lymphadenopathy, contrast is required Our patient’s high resolution CT

• What is the diagnosis? • This patient is showing the early stages of usual interstitial pneumonitis • The patient is a steel worker • Notice the thickening of the bronchial walls and the ground glass opacities* in the posterior lung A 60 yo man with a 40 pack year smoking history comes in with hemoptysis

• Which radiologic test should you order first? • Chest radiography PA and lateral • Will quickly allow for the visualization of large thoracic pathology • If the cause of hemoptysis is not apparent from radiography, which test next? • CT chest with contrast • Contrast is important here because it will allow for enhancement of the peripheral arteries in the lung to better visualize a source of bleeding, it also allows for better visualization of the mediastinum • Common causes of hemoptysis include chronic bronchitis, bronchiectasis, pneumonia, fungal infections, tuberculosis, and malignancy Our patient’s chest radiograph

• Why is the patient coughing up blood? • Did you notice the right hilar opacity? • With this patients smoking history, you astutely decide to order a Chest CT with contrast Here is our patient’s contrast enhanced CT

• Why is the patient coughing up blood? • There is a right hilar opacity which turned out to be cancer

Because this is a contrast enhanced scan, mediastinal and hilar lymphadenopathy is easier to appreciate Incidental Pulmonary Nodules

• Sometimes, imaging can reveal incidental findings unrelated to the diagnostic question. For example, a chest CT may reveal pulmonary nodules. • How should clinicians work-up this finding?

• The Fleischner Society publishes guidelines often employed by physicians to determine the necessary management in such cases • The 2017 guidelines can be reviewed at the following: • https://doi.org/10.1148/radiol.2017161659 Additional Pathologies to Consider in SOB COPD

• Lung hyperinflation • Diaphragmatic flattening • Increased lung field lucency Asthma

• Patients with asthma will usually have a completely normal CXR, unless they are having an exacerbation secondary to respiratory pathology (i.e. pneumonia)

• Again, there is no need to image known uncomplicated asthma A 72 yo M presents to urgent care with a Headache

• What are some of the so-called “red flags” that would prompt immediate imaging instead of conservative management?

 Acute onset severe headache  Immunocompromised  Optic disc edema  Currently pregnant  Recent head trauma  New headache at > 50 years of age  Neurological deficits  New headache of likely trigeminal origin  Known/suspected cancer  Chronic headache with new features

• What imaging modality would you get if one of these was present?

 Specific modality and contrast need will depend on symptoms and circumstances, but usually either CT or MRI Head is selected This 72 yo patient has never had issues with chronic headaches, but recently began experiencing a 7/10 diffuse headache that wakes him up at night…. • Would you image this patient? YES! Individuals older than the age of 50 with a new headache should receive imaging

• What type of imaging would you order? CT Head without contrast, MRI head without contrast, or MRI WWO are appropriate options You prudently order a CT Head without contrast, from which an image is shown below:

What is a probable diagnosis?

There is a mass in the patient’s right parietal lobe, which is concerning for tumor.

Generally, the exact type of tumor must be confirmed with tissue biopsy.

Note the hyperdense elements found within the center of the mass. This likely represents blood products from local hemorrhage.

In this particular case, the diagnosis was glioblastoma multiforme. It is important to remember that most headache’s will have normal imaging! A 34 yo F endorses chronic joint pain in both hands at annual wellness exam

• What are some disease processes that should be suspected when patient’s endorse chronic joint pain?  Rheumatoid Arthritis  Osteoarthritis  Gout  Pseudogout  Seronegative spondyloarthropathies • What role does imaging play in diagnosing suspected inflammatory arthropathies?

 Imaging alone is usually not sufficient for the diagnosis of a specific condition. However, it can be helpful in both confirming the presence of an inflammatory process and providing clues that can establish a diagnosis in combination with clinical exam and lab findings.

 An X-ray of the painful joint(s) is usually the best initial imaging to order. It should be ordered when clinical findings alone are not sufficient to establish a specific diagnosis. Rheumatoid Arthritis vs. Osteoarthritis • Differentiating RA from OA is a challenging task faced by many outpatient physicians. Below, we summarize a few notable guidelines that can assist with diagnosis:

Rheumatoid Arthritis: Osteoarthritis:

 Symmetric presentation  Presentation can be asymmetric  Seropositive  Seronegative  Can be associated with other  Usually an isolated process disease processes, such as without systemic findings interstitial lung disease  Hard, bony joints  Warm, tender joints  Older onset  Ulnar deviation of fingers  Classically involves the DIPs more  Younger onset often than RA  Morning stiffness often lasting  Morning stiffness usually resolves > 30 minutes in < 30 minutes To supplement clinical findings, an X-ray of both hands is ordered for our patient. The X-ray of the R hand is shown below:

What is the most likely diagnosis? Rheumatoid Arthritis

What available clinical information assisted with this diagnosis? The patient is a young female with symmetric onset What findings on imaging support the diagnosis of RA?

Erosions at the metacarpophalangeal joints Ulnar deviation of the fingers Relative sparing of the DIPs A 58 yo F visits clinic for a wellness exam

• The patient in this scenario has had poor access to healthcare. She is a current smoker, with 40 pack-year history of smoking. She does not have a significant PMH, and is not currently on any medications. What imaging studies should the physician order? (Consider reviewing the USPSTF screening guidelines if you need assistance)

 Screening mammogram  Low-dose CT chest  All females aged 50-74 should  Given the patient’s smoking have biennial screening history and active smoker status, mammograms for breast cancer she will need annual lung cancer screening with low-dose CT A screening mammogram is appropriately ordered, shown below:

Are there any findings concerning for breast cancer? No, there are no masses or microcalcifications suggestive of underlying malignancy.

What is the recommended next step?

Repeat screening mammogram after two years

What would have been the next step if there was concern for breast cancer? Diagnostic mammogram A 46 yo F presents for annual wellness exam

• When would imaging of this patient’s thyroid be appropriate?

 Palpable thyroid nodule  Diffusely enlarged thyroid  Hyperthyroidism (or any form of thyrotoxicosis)  Pre- or post-operative assessment of known thyroid cancer

• What imaging modality would you initially order in the case of a palpable thyroid nodule in a euthyroid patient?

 Ultrasound of the thyroid The patient in this case is asymptomatic, but is noted to have a palpable thyroid nodule on physical exam. An ultrasound of the thyroid is appropriately ordered, shown below: The American Thyroid Association (ATA) publishes guidelines concerning sonographic evaluation of thyroid nodules. What concerning features does this nodule have?

Calcifications

Hypoechoic nodule

Assuming an intermediate to high suspicion for thyroid cancer, what is the next step in diagnosis? FNA The vast majority of thyroid nodules will NOT be malignant! END