THESIS TITLE: DIAGNOSTIC IMAGING PATHWAYS This thesis is presented for the degree of Master of Medical Science by Research of the University of Western Australia by Ravinder Dhillon (MBBS) School of Medicine and Pharmacology University of Western Australia 2006 DECLARATION FOR THESES CONTAINING PUBLISHED WORK AND/OR WORK PREPARED FOR PUBLICATION 1 This thesis does not contain work that I have published, nor work under consideration for publication. The thesis is completely the result of my own work, and was substantially conducted during the period of candidature, unless otherwise stated in the thesis. N/A Signature………………………………. 2 This thesis contains sole-authored published work and/or work prepared for publication. The bibliographic details of the work and where it appears in the thesis is outlined below. N/A Signature……………………………… 3 This thesis contains published work and/or work prepared for publication, some of which has been co- authored. The bibliographic details of the works and where they appear in the thesis are set out below. (The candidate must attach to this declaration a statement detailing the percentage contribution of each author to the work. This must been signed by all authors. Where this is not possible, the statement detailing the percentage contribution of authors should be signed by the candidate’s Coordinating Supervisor). PJ Bairstow, R Mendelson, R Dhillon and F Valton. Diagnostic imaging pathways: development, dissemination, implementation, and evaluation. International Journal for Quality in Health Care 2006; Volume 18, Number 1: pp 51-57. The contents of this published paper appear in Chapter 3 (Medium of Distribution), Chapter 4 (Dissemination and Implementation), Chapter 5 (Evaluation and feedback) and Chapter 6 (Discussion) of this thesis. Signature……………………………… Dr Ravinder Dhillon Clinical Professor Richard Mendelson (Coordinating Supervisor) Declaration The contents of the paper titled “Diagnostic imaging pathways: development, dissemination, implementation and evaluation” published in the International Journal for Quality in Health Care 2006; Vol 18, Number 1: pp 51-57 form a part of this thesis and I have the permission of the co- authors - Dr Richard Mendelson, Dr Phillip Bairstow and Mr Frederic Valton, to include this work in my thesis. Dr Ravinder Dhillon Dr Phillip Bairstow Clinical Professor Richard Mendelson Professor Ian Puddey (Coordinating Supervisor) (Co-Supervisor) ii Contents CONTENTS.....................................................................................................................ii THESIS ABSTRACT.....................................................................................................vi CONTRIBUTIONS TO THESIS................................................................................viii PUBLICATIONS AND PRESENTATIONS...............................................................xi ACKNOWLEDGMENTS.............................................................................................xii CHAPTER 1: Introduction 1.1 Introduction.........................................................................................2 1.2 Hypothesis and Aims...........................................................................7 CHAPTER 2: Clinical and academic content 2.1 Objective........................................................................................9 2.2 Methodology..................................................................................9 2.3 Results.........................................................................................10 2.4 Diagnostic Imaging Pathways.....................................................12 Cardiovascular system • Abdominal Aortic Aneurysms...............................................13 • Blunt Traumatic Injury of Thoracic Aorta............................15 • Deep Vein Thrombosis..........................................................19 • Hypertension..........................................................................22 • Lower Limb Claudication......................................................26 • Spontaneous Aortic Dissection..............................................29 • Suspected Myocardial Infarction...........................................32 Central Nervous System • Acute Headache.....................................................................36 • Chronic Headache..................................................................40 • Cord Compression.................................................................44 • Dementia................................................................................47 • Head Trauma.........................................................................52 • Investigation of Seizure.........................................................54 • Orbital Pathology...................................................................59 • Pituitary Fossa Lesion...........................................................62 iii • Stroke.....................................................................................64 • Transient Ischaemic Attacks..................................................68 Ear, Nose & Throat • Chronic Sinusitis....................................................................72 • Salivary Gland Swelling........................................................76 • Tinnitus..................................................................................79 Endocrine System • Bone Densitometry................................................................82 • Incidental Adrenal Mass on CT.............................................84 • Investigation of Cushing’s Syndrome...................................87 • Phaeochromocytoma.............................................................90 • Primary Hyperaldosteronism.................................................93 • Primary Hyperparathyroidism...............................................96 • Solitary Thyroid Nodule......................................................100 • Thyroid Incidentaloma........................................................103 Gastrointestinal System • Acute Bloody Diarrhoea......................................................105 • Acute Gastrointestinal Bleeding..........................................109 • Acute Left Iliac Fossa Pain..................................................114 • Acute Pancreatitis................................................................118 • Acute Right Iliac Fossa Pain...............................................122 • Acute Right Upper Quadrant Pain.......................................126 • Blunt Abdominal Trauma....................................................129 • Chronic Pancreatitis.............................................................134 • Dyspepsia.............................................................................137 • Dysphagia............................................................................141 • Imaging Prior To Laparoscopic Cholecystectomy..............145 • Investigation of Cholestatic Jaundice..................................151 • Staging of Colorectal Cancer...............................................156 • Staging of Oesophageal Cancer...........................................160 • Suspected Bowel Obstruction..............................................163 • Suspected Intra-abdominal Abscess....................................168 Genitourinary System • Acute Renal Failure.............................................................172 iv • Acute Renal Transplant Dysfunction..................................175 • Lower Urinaray Tract Symptoms (LUTS) .........................178 • Painless Haematuria............................................................181 • Renal Colic..........................................................................185 • Renal Mass..........................................................................190 • Scrotal Mass........................................................................194 • Scrotal Pain..........................................................................197 • Staging of Prostate Carcinoma............................................200 • Staging of Renal Cell Carcinoma........................................204 Musculoskeletal System • Back Pain.............................................................................207 • Bone Metastases..................................................................212 • Cellulitis with Suspected Bone Infection............................213 • Knee Pain............................................................................218 • Multiple Myeloma...............................................................223 • Shoulder Pain.......................................................................225 • Spinal Infection....................................................................229 • Spinal Trauma......................................................................234 • Suspected Avascular Necrosis.............................................239 • Suspected Scaphoid Fracture...............................................242 • Suspected Stress Fracture...................................................246 Obstetrics & Gynaecological System • First Trimester Bleeding .....................................................249 • Pelvimetry............................................................................253 • Suspected Ectopic Pregnancy..............................................255 • Third Trimester Pregnancy..................................................259