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RADD Report Writing Lecture > Midterm > Flashcards

Midterm Flashcards

1
Q

Role of report

A

Record findings
Documentation in med-legal circumstances
Provide a permanent record in case films lost or damaged
Provide communication with other health care professionals
Assist with indications, contra-indications, and prognosis for care

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2
Q

The global fee consists of

A

A technical component and a professional component

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3
Q

The technical fee is approximately

A

2/3 of the global fee

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4
Q

The professional comoponent is approximately

A

1/3 of the global fee

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5
Q

Time spent marking films and/or discussing the patient’s findings ___ part of the global fee

A

IS NOT

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6
Q

Technical component

A

Represents the production of the radiograph

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7
Q

The technical component includes

A

Equipment costs, time to position the patient, and time to create the image

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8
Q

The professional component is a full written typed reports

A

In the ABCS format as will be presented in this class

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9
Q

Check list type sheets ____ constitute a written report to satisfy the professional component

A

DO NOT

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10
Q

When using the global fee, there is a legal obligation to

A

Have a written report - otherwise, constitutes fraud

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11
Q

Failure to report an imaging study is analogous to

A

Performing a physical exam but not recording the findings

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12
Q

In order to meet requirement GA law states

A

You must make an appropriate diagnosis or at least a differential diagnosis

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13
Q

You are responsible for evaluating

A

The area of chief complaint

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14
Q

Local defense - NOT THE CASE

A

The idea that you will only be held to teh same standard as another DC in your locale

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15
Q

An action brought by the patient or when deceased the family against the practitioner for a crime of omission or comission - may result in punitive damages
Covered by malpractice insurance

A

MALPRACTICE

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16
Q

Any complaint to the board must be investigated
May or may not also have a malpractice claim
Often board complaints are not covered by malpractice insurance
Adverse decisions lead to licensure penalties to include revocation of the license

A

Board action

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17
Q

Responsibilities/liabilities when using an outside source

A

No opinion
Second opinion
Share the professional component

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18
Q

Things that alter liability even if films are sent out for review

A

Bad quality
Lack of opposing views
Failure to follow through on radiologist’s recommendations

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19
Q

Reasons to get a second opinion on x-ray

A 
Red flags
Complicated history or exam
Failure to respond to care as expected
Unexplained deterioration of the condition
Confirming the DC’s interpretation
Medicolegal support
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20
Q

Red flag indicators are often associated with

A

Significant underlying disease

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21
Q

Complicated history or exam

A

When patient aren’t like everybody else

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22
Q

Failure to respond to care as expected may point to

A

Misdiagnosis, or overlooked subtle finding

May lead to a decision on the next best step and the second opinion provider can assist even if not part of the report

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23
Q

Unexplained deterioration of the condition

A

Worsening of symptoms especially with care is often associated with significant underlying condiitons

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24
Q

Confirming the DC’s interpretation

A

When you have come to a diagnosis that isn’t an everyday finding a second opinion to confirm the interpretation is warranted

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25
Q

Medicolegal support

A

In personal injury and worker’s compensation cases confirmation of findings is vital to teh outcome of the case

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26
Q

Digital transmission to send films out for review

A

Direct software to software connection

Transferring through the receiver’s VPN

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27
Q

Taking a digital photo and sending as an email

A

Is not really legal on both ends

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28
Q

Snail mail sending films

A

Purchase mailing envelopes thorugh film suppliers

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29
Q

Pertinent clinical information

A

Recent trauma (when, where, etc)
Significant past history (tumor, metabolic disease, etc)
Exam findings that aren’t like everybody else

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30
Q

You have a quesiton area on the film

A

Identify the finding with an arrow, circle, etc
Or write a brief note noting your exact question like on the lateral film what is the transverse lucency through the posterior inferior body of L4

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31
Q

Comopnents of the radiology report

A 
Biographical information
History
Body of report
Conclusions/impressions
Recommendations 
Signature
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32
Q

Biographical information

A 
Patient name
Patient age
Patient number
Date of exam
Views taken
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33
Q

History

A

Optional
Helpful when clinically significant
Should be brief (inversion injury with pain at the base of the 5th metatarsal)

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34
Q

Body of report

A 
Meat of the report
Descriptions, NOT conclusions
Precise descriptions
Brief but complete
Complete grammatically correct sentences
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35
Q

Body of report parts

A

A - alignment
B - bone density
C - cartilage
S - soft tissue

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36
Q

Alignment

A

Not listings
Pelvic inferiority, left or right curves, anterolisthesis, retrolisthesis, basilar invagination, dislocations/separations, valgus/varus, etc
Be specific

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37
Q

Bone density

A

Hardest part

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38
Q

Cartilage

A

Changes around joint space

Changes to joint space

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39
Q

Anterior osteophytes are noted at C5/C6

A

Cartilage

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40
Q

Moderate disc narrowing is noted at C5/6

A

Cartilage

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41
Q

Anterior soft tissue markings are within normal limits

A

Soft tissues

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42
Q

Brief
Phrases when possible
(Degenerative disc disease C5/6)

A

Conclusions (impressions)

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43
Q

Some radiologists combine with conclusions

Clearly identify what and why

A

Recommendations

44
Q

A universal compression fracture is noted at L3. Continued assessment with MRI or a combination of bone scan and lab work is necessary to differentiate osteoporosis, metastasis or multiple myeloma as the cause

A

Recommendations

45
Q

Definitions for guidelines
Acute
Subacute
Chronic

A

1-4 weeks
5-12 weeks
Greater than 12 weeks

46
Q

Adult patient acute neck injury x-rays indicated when any are present

A 
Over 65
Paraesthesias in extremities
Not a simple rear end collision
Immediate cervical pain onset
Presence of midline cervical tenderness
Patient unable to actively turn head to 45 degrees in both directions
47
Q

Acute neck injury x-rays NOT indicated when ALL of these are fulfilled

A

Simple rear end collision
Delayed cervical pain onset
Absence of midline cervical tenderness

48
Q

X-rays ___ indicated in acute uncomplicated neck pain

A

ARE NOT

49
Q

Uncomplicated means

A

Nontraumatic without underlying neurological findings or red flags

50
Q

Acute neck pain is generally not due to

A

Conditions that can be seen on x-ray

51
Q

X-rays are indicated in acute uncomplicated neck pain in certain circumstances

A

If prior to seeing you the patient has had treatment with no success take x-rays
Consider x-ray or other tests in the absence of expected response to your care or if there is worsening of symptoms
BE SURE TO RECOGNIZE RECURRENT PAIN VERSUS ACUTE PAIN

52
Q

X-rays ____ indicated in nontraumatic neck pain AND arm pain or paraesthesia

A

ARE

53
Q

X-rays ___ indicated in uncomplicated subacute and chronic neck pain with or without radicular symptoms

A

ARE

4 weeks or longer

54
Q

X-rays ___ indicated with complicated (red flags) neck pain

A

ARE

55
Q

Patient less than 20 and over 50, particularly with S and S suggesting systemic disease

A

x-rays YES

56
Q

Significant activity restriction greater than 4 weeks

A

YES x-rays

57
Q

No resaponse to care after 4 weeks

A

X-rays YES

58
Q

Intractable pain, constant or progressive S&S

A

X-rays YES

59
Q

Neck rigidity in the sagittal plane in the absence of trauma

A

X-rays YES

60
Q

Intractable pain - doesn’t go away, no position to releave the pain. Consistent or progressive signs and symptoms - hurts all the time no matter what

A

X-rays YES

61
Q

2 things create dysphagia

A

OA and a tumor

62
Q

Dysphagia

A

YES

63
Q

Impaired consciousness

A

YES

64
Q

Cranial n signs, pathological reflexes, long tract signs

A

YES

65
Q

High risk lig laxity populations/suspected atlantoaxial instability

A

YES

66
Q

Arm or leg pain with movement

A

YES

67
Q

Cancer phobia

A

YES

68
Q

Suspected neoplasm

A

YES

69
Q

Suspected infection

A

YES

70
Q

Suspected failed surgical fusion

A

YES

71
Q

Progressive painful or structural deformity

A

YES

72
Q

Elevated lab exam and positive S&S

A

YES

73
Q

X-rays ____ indicated with recent (<2 weeks) acute T, L, or T/L trauma with ANY of these

A

ARE

74
Q

Moderate to severe localized back pain

A

YES

75
Q

Midline tenderness on palpation

A

Yes

76
Q

Neurological deficits

A

Yes

77
Q

MVA >50 mph

A

YES

78
Q

Fall of 10 ft or more

A

YES

79
Q

X-rays ARE NOT indicated with recent (<2 weeks) acute T, L, or T/L trauma with

A

Absence of pain
Normal ROM
Absence of neurological deficits

80
Q

X-rays ____ indicated in acute patients with uncomplicated LBP, T pain

A

ARE NOT

81
Q

Uncomplicated means

A

Nontraumatic
No neurological deficits
No red flags

82
Q

X-rays ____ initially indicated with subacute or chronic LBP, T pain AND no previous treatment trial

A

ARE NOT

83
Q

When no prior treatment has been attempted, a trial period of 4-6 weeks is suggested

A

Prior to radiographs

84
Q

X-rays are indicated in the absence of expected treatment response or worsening after

A

4-6 weeks

85
Q

X-rays ___ initally indicated with nontraumatic acute LBP AND sciatic (suspicion of disc herniation

A

ARE NOT

86
Q

X-rays are not initially indicated with nontraumatic acute LBP and sciatic (suspicion of disc herniation) unless

A 
Patient is >50
Or has progressive neurological deficits
Or has unexpected response to care after 4-6 weeks
Or worsens with care
MRI would be of value
87
Q

Signs of disc herniation - need 3 of 5 (consistent to same N level)

A

Primarily leg pain
Leg pain confined to dermatome
Neural stretch tests recreate or exacerbate the leg pain
At least 2/4 neurologic findings consistent with dermatome - muscle weakness, decreased reflex, abnormal pinwheel, atrophy
MR or CT correlating to dermatome

88
Q

X-rays ____ indicated with suspected degenerative spondylolisthesis/lateral recess stenosis

A

ARE

89
Q

Signs of degenerative spondylolisthesis in lumbar spine

A

Primarily scleratogenous leg pain (one or both legs)
Comes and goes
Often reduced by leanign forward or sitting down
No neurologic findings
Very common
4 F’s: fat, female, forty, L4

90
Q

X-rays ____ indicated in complicated (red flag) thoracic and lumbar pain

A

ARE

91
Q

S&S of systemic disease especially <20 or >50

A

Yes

92
Q

Absence of expected treatment results or worsening avter 4-6 weeks

A

Yes

93
Q

Significant activity restriction > 4 weeks

A

Yes

94
Q

Unrelenting pain at rest

A

Yes

95
Q

Constant or progressive S&S

A

Yes

96
Q

Suspected inflammatory spondyloarthropathy

A

Yes

97
Q

Suspected compression fracture

A

Yes

98
Q

Suspected neoplasm

A

Yes

99
Q

Suspected infection

A

Yes

100
Q

Suspected failed surgical fusion

A

Yes

101
Q

Progressive or painful structural deformity

A

Yes

102
Q

Elevated lab and positive S&S

A

Yes

103
Q

Criteria for inflammatory back pain

A

Morning stiffness for > 30 min
Improvement of back pain with exercise but not resat
Awakening in the second half of the night due to back pain
Alternating buttock pain

104
Q

Signs of suspected neoplasm

A 
Considerable LBP >50
Hx of CA
Unexplained weight loss
Failure of conservative care
Intractable pain
ESR >50mm/hr
Systemically unwell
Lymphadenopathy
105
Q

Special circumstances for x-ray

A

Pt unable to give a reliable Hx
Crippling cancer phobia
Need for immediate decision about career or athletic future or legal evaluation
Hx of significant radiographic abnormalities elsewhere
Hx of finding from outside study (abdomen, etc) that requires spine evaluation

106
Q

X-rays ___ indicated with non painful non progressive adult scoliosis

A

ARE NOT

107
Q

In a skeletally mature patient, scoliosis is

A

> 10 degrees

RADD Report Writing Lecture (1 decks)

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